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1. 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 DayVegetables
Measure 4-6 2-3 1I - A Chinese cabbage, alugbati leaves, ampalaya fruit/ leaves, 1 cup,
raw bamboo shoot, banana heart, cabbage, cauliflower, celery, chayote fruit/leaves,
cucumber, eggplant, gabi leaves, cup, cooked kangkong, lettuce, malunggay leaves,
mushroom, okra, 2 cups, raw petsay, radish, saluyot, squash, string beans, tomato, upo,
sitsaro. Seaweed. 1 cup, cooked cup, rawI B carrot, coconut shoot (ubod), kamansi,
langka hilaw, patani, mungbean sprout (toge), singkamas, cowpea pods, cup, cooked
stringbeans pod.Fruits Measure 4-6 2-3 1 1 whole fruit (for very Banana (any kind),
mango, pineapple, papaya, watermelon, large or small chopped) 1 jackfruit, cup In Fruit
juice Calamansi, orange, suha, pineapple, mango cup Fresh buko juice 1/3 cupBeans
and Legumes Measure 4-6 2-3 1 Baguio beans, black beans, garbanzo beans, peas 1 cup
cookedNuts and Seeds Peanut, cashew nut cupRice, Grains, Cereals, Breads & Pastas
Measure 4-6 2-3 1 Rice, cooked cup, packed
2. 2 slice or 2 pc. Bread (Pan de amerikano, pan de leche, monay, pan de sal) (average of
6x5x4 cm) n size Wheat, oats, noodles, spaghetti, macaroni I cupMeats and Fish Measure
4-6 2-3 1 Lean meat of beef, pork 1 slice matchbox size 1 small leg, breast Chicken
(hita, laman, pitso) (6 cm long), laman, matchbox size Food Groups Servings Per Day
Measure 4-6 2-3 1 Internal Organs / Variety of Meat - Blood (Dugo) pork, beef,
chicken gizzard (balun-balunan chicken); heart, liver, lungs, cup spleen, small
intestines, uterus (pork, Beef) 1 slice (7x3x2 cm) for big fish Fish bangus, matambaka,
bariles, tune, lapu-lapu, hito, 1 serve average of galunggong, (large and medium size fish)
( 18-22x4-5x1/2-1 cm) for medium fish - small size; sapsap, tilapia, tamban, dilis
cupOther Seafoods Measure 4-6 2-3 1 Shrimps (alamang) 1 tbsp. Crabs (alimango) 1
tbsp. Lobster 2 tbsp. 2-3 cups with shell or 1 Sea shells (kuhol, susong pilipit, taho,
talaba) cup shelledDairy and Eggs Measure 4-6 2-3 1 Chicken egg / salted ducks egg 1
pc Quials egg 9 pieces Cheddar cheese 1 slice ( 6x3x2cm) Cheese filled 1 slice (6x3x2
cm) Fresh milk (cow/goat), powdered filled milk 1 cup Butter, margarine, mayonnaise,
cream, gravy, refined sugar, 1 tbsp or sparingly oilPart B : Daily Lifestyle
SurveyDirection: 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. 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 onlyExercise: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 felt3. 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 feltFood Frequency:
4. 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 never5. 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 never6. 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
never7. 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
never8. 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 never9. 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 never10. 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 never11. 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 ***Pmv-12-27-06