NUTRITIONAL STATUS SURVEY

(By P. M. Veroy RN, MAN)

Personal Data:

Name: (Optional)_____________________________________ Age________ Gender_________ Height_________ Weight (Kg) ________Religion: ( ) R. Catholic ( ) SDA ( ) Islam; Others please specify:_____________________

Directions:

1. Be sure to fill out the questionnaire as accurately as possible and avoid underestimating your food intake. 2. Your food choices should cover the past three (3) months until the present to show what you eat in your

regular meals everyday.3. Mark check (/) the options that indicate serving per day with each corresponding food classification.

Part A: Daily Food Consumption Survey:

Food Groups Servings Per Day

Vegetables Measure 4-6 2-3 1

I - A Chinese cabbage, alugbati leaves, ampalaya fruit/ leaves, bamboo shoot, banana heart, cabbage, cauliflower, celery, chayote fruit/leaves, cucumber, eggplant, gabi leaves, kangkong, lettuce, malunggay leaves, mushroom, okra, petsay, radish, saluyot, squash, string beans, tomato, upo, sitsaro. Seaweed.

1 cup, raw

½ cup, cooked

2 cups, raw

1 cup, cooked

I – B carrot, coconut shoot (ubod), kamansi, langka hilaw, patani, mungbean sprout (toge), singkamas, cowpea pods, stringbeans pod.

½ cup, raw

½ cup, cooked

Fruits Measure 4-6 2-3 1

Banana (any kind), mango, pineapple, papaya, watermelon, jackfruit,

1 whole fruit (for verylarge or small chopped) 1

cup

Calamansi, orange, suha, pineapple, mangoIn Fruit juice ¼

cup Fresh buko juice 1/3 cup

Beans and Legumes Measure 4-6 2-3 1

Baguio beans, black beans, garbanzo beans, peas 1 cup cooked

Nuts and Seeds

Peanut, cashew nut ¼ cup

Rice, Grains, Cereals, Breads & Pastas Measure 4-6 2-3 1

Rice, cooked ½ cup, packed

Bread (Pan de amerikano, pan de leche, monay, pan de sal)2 slice or 2 pc.

(average of 6x5x4 cm) n size

Wheat, oats, noodles, spaghetti, macaroni I cup

Meats and Fish Measure 4-6 2-3 1

Lean meat of beef, pork1 slice matchbox size

Chicken (hita, laman, pitso)1 small leg, ¼ breast (6 cm long), laman,

matchbox size

Food Groups Servings Per Day

Internal Organs / Variety of Meat -

Measure 4-6 2-3 1

Blood (Dugo) – pork, beef, chicken gizzard (balun-balunan chicken); heart, liver, lungs,

spleen, small intestines, uterus (pork, Beef)¾ cup

Fish – bangus, matambaka, bariles, tune, lapu-lapu, hito, galunggong, (large and medium size fish)

1 slice (7x3x2 cm) for big fish

1 serve average of ( 18-22x4-5x1/2-1 cm) for medium fish

- small size; sapsap, tilapia, tamban, dilis ¼ cup

Other Seafoods Measure 4-6 2-3 1

Shrimps (alamang) 1 ¼ tbsp. Crabs (alimango) 1 tbsp. Lobster 2 tbsp.

Sea shells (kuhol, susong pilipit, taho, talaba)2-3 cups with shell or 1

cup shelledDairy and Eggs Measure 4-6 2-3 1 Chicken egg / salted duck’s egg 1 pc Quial’s egg 9 pieces Cheddar cheese 1 slice ( 6x3x2cm) Cheese filled 1 slice (6x3x2 ½ cm) Fresh milk (cow/goat), powdered filled milk 1 cup Butter, margarine, mayonnaise, cream, gravy, refined sugar,

oil1 tbsp or sparingly

Part B : Daily Lifestyle Survey Direction: Mark check (/) your choice of answer on the underlined space before the option.

Tobacco Use:1. What best describes your use of cigarettes, pipes, and cigars? ____ Never smoked ____ Former smoker ____ Smoker2. How many sticks or pack(s) consume per day? _______________________________.Alcohol:

3. Do you drink alcohol? _____No ____ Yes4. If YES, what type of alcohol? _____ (beer any kind, gin, rum, whisky, brandy)

_____ (tuba, lambanog, grape wine, sioktong)5. How many glasses of alcohol do you drink per day? _____ 5 glasses or more, _____ 3-5 glasses,

_____ 1-3 glasses, _____on occasion only Exercise:6. Do you exercise regularly? ____No ____Yes. If YES; how many times a week? ____everyday ____ 2-3 times, ___1-2 times

____once a week7. Duration per exercise; ____1 hour or more, ___45mins.-1 hour, ____ 30-45 minutes, ____ 15-30 minutes8. Type of exercise: ____Jogging, _____aerobic work-out, _____biking, ____swimming, ____weight lifting,

others please specify:______________________________________Water Intake:9. How much glasses of plain water do you consume daily? ____10-12, ____ 8-10, ____ 6-8, _____ 5 or lessWaste Elimination:10. How often do your bowels eliminate? ____twice daily, ____once daily, ____3-4 times a week,

____once or twice a week onlySleeping Habit:11. How many hours you usually sleep a day? ____8-10, ____6-8, ____4-6, ____less than 4 hours.12. What type of sleeping pattern? ____ Continuous at night time, ____ With 3 or more wakes in between sleep

at night time, ____irregular frequency at any time of the day, Nutritional Supplement: 13. Do you take nutritional supplement? ____ No, ____ Yes. If YES, which type? ____ vitamins/minerals, ____ amino acids, ____ herbs.14. How often do you take it? ____ 2 times or more per day, ____ once daily, _____ every other day,

____ 2-3 times a week.

Part C: Food Eating Habits Survey:Direction: Mark check (/) your choice of answer on the underlined space before the option.

1. How many times a week do you eat breakfast, lunch, or dinner in a RESTAURANT or FAST FOOD PLACE? (Include all food prepared away from home, such as take-out food and home delivered food and ready-to-eat or deli food to take home. Do not include brown bag meals prepared at home.)

___ Never eat out, ___ 1-3 times per week, ___ 4-6 times per week, ___ 7 or more timesHunger:2. How hungry do you usually feel BEFORE you eat meals or snacks? MEALS SNACKS

___Do not eat meals ___Do not eat snacks___Not at all hungry ___Not at all hungry___A little hungry ___A little hungry___Neither hungry or full ___Neither hungry or full___Moderately hungry ___Moderately hungry___As hungry as I have ever felt ___As hungry as I have ever felt

3. How full do you usually feel AFTER you eat meals or snacks?MEALS SNACKS

___Do not eat meals ___Do not eat snacks___Not at all full ___Not at all full___A little full ___A little full___Neither hungry or full ___Neither hungry or full___Moderately full ___Moderately full___As full as I have ever felt ___As full as I have ever felt

Food Frequency:

4. How often do you eat HIGH FAT MEATS such as marbled or untrimmed beef, beef, pork, hamburger meat, poultry with skin, sausage, hotdogs, bologna, longaniza, chorizo, tocino and salami?____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never

5. How often do you eat FRIED FOODS such as French fries, fried meat, fried poultry, fried fish, potato or corn chips, fried vegetables, or fried cheese?____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never

6. How often do you use BUTTER or STICK MARGARINE with your food?____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never

7. How often do you eat HIGH-FAT BAKED FOODS such as biscuits, cornbread, croissants, waffles, or pancakes? (Sweet baked muffins and cookies, not included)____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never

8. How often do you eat HIGH-FAT CONVENIENCE FOODS such as regular frozen dinners, entrees, or frozen pizza?____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never

9. How often do you eat HIGH SALT SNACKS, such as popcorn, high-fat crackers, potato chips, salted dried peas, peanuts, corn, and other snack mixes?____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never

10. How often do you eat HIGH-FAT, HIGH SUGARED FOODS such as ice cream, puddings, cakes, muffins, cookies, pies, doughnuts, or chocolate candy?____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never

11. How often do you eat HIGH-SUGAR FOODS that are low-fat or fat-free such as desserts, cookies, frozen yugort, regular drinks, and hard candy?____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never

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Pmv-12-27-06