ADOL

*7-Day Activity Table

Time Days of the Week & Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 am
2 am
3 am SLEEPING
4 am
5 am WAKE UP
6 am EAT BREAKFAST
7 am
8 am
9 am SCHOOL
10 am
11 am
12 nn EAT LUNCH
1 pm USE
2 pm CELLPHONE OR
3 pm SCHOOL WATCH
4 pm TELEVISION
5 pm
6 pm DO SCHOOL WORKS
7 pm
8 pm EAT DINNER
9 pm USE CELLPHONE OR WATCH TELEVISION
10 pm USE
11 pm CELLPHONE OR
12 MN SLEEPING WATCH
TELEVISION

*3-day Diet Recall

MEALS Date & Day Date & Day Date & Day
Breakfast 1 Meat loaf, 1 cup 3 pieces of Egg, 1 cup of rice
6 AM of rice and 1 cup shrimp, 1 cup of And 1 cup of water
of water rice and coffee
Snacks (if any) None None None
Lunch (time) 1 cup of munggo, 3 pieces of Pakbet, 1 cup of
1 cup of rice and 1 shrimp, 1 cup of rice and 1 cup of
cup of water rice and 1 cup of water
water
Snacks (if any) 3 pieces of Cookies Pancit Canton
pandesal and
coffee
Dinner (time) 1 cup of munggo, Fried tilapia, 1 Pakbet, 1 cup of
 1 cup of rice and 1 cup of rice and 1 rice and 1 cup of
cup of water cup of water water
Snacks (if any) None None None
Total Fluid ___mL ___mL ___mL
Intake

SENIOR CITIZEN

*7-Day Activity Table

Time Days of the Week & Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 am
2 am SLEEPING
3 am
4 am WAKE UP
5 am CLEANING/SWEEPING
6 am EAT BREAKFAST
7 am
GOES TO THE MARKET
8 am
9 am
COOKING
10 am
11 am
EAT LUNCH
12 nn
1 pm
WATCH TELEVISION
2 pm
3 pm
4 pm SLEEPING
5 pm WAKE UP
6 pm COOKING
7 pm EAT DINNER
8 pm USE CELLPHONE
9 pm
10 pm
11 pm SLEEPING
12 MN
*3-day Diet Recall
MEALS Date & Day Date & Day Date & Day
Breakfast (time) 1 cup of coffee 1 cup of milk 3 pieces of
pandesal with
coffee
Snacks (if any) None None None
Lunch (time) 1 cup of rice and 1 cup of rice and 1 cup of rice and
Chopsuey and 1 Pakbet and 1 cup Munggo and 1 cup
cup of water of water of water
Snacks (if any) Coffee None Coffee
Dinner (time) 1 cup of rice and 1 cup of rice and 1 cup of rice and
Chopsuey and 1 Pakbet and 1 cup Munggo and 1 cup
cup of water of water of water
Snacks (if any) None None None
Total Fluid ___mL ___mL ___mL
Intake

CHILD
*7-Day Activity Table
Time Days of the Week & Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 am
2 am
SLEEPING
3 am
4 am
5 am WAKES UP
6 am BREAKFAST
7 am
8 am WAKES UP
SCHOOL
9 am BREAKFAST
10 am PLAYING
11 am
LUNCH
12 nn
1 pm
2 pm PLAYING
3 pm
4 pm
SCHOOL WORKS
5 pm
6 pm
DINNER CHURCH
7 pm
8 pm DINNER
WATCH TELEVISION
9 pm
10 pm
SLEEPING
11 pm
 12 MN

*3-day Diet Recall

MEALS Date & Day Date & Day Date & Day
Breakfast (time) Hotdog sandwich 1 Longganisa and 1 Hotdog and 1
and 1 cup of milo 1 cup of rice and 1 cup of rice and 1
cup of Milo cup of milo
Snacks (if any) None None None
Lunch (time) Fried pork with Fried chicken with 1 Hotdog and 1
one cup of rice one cup of rice cup of rice and 1
and one cup of and one cup of cup of water
water water
Snacks (if any) Sugar with 1 cup Piattos Toasted bread with
of rice orange juice
Dinner (time) Fried pork with Fried chicken with 1 Hotdog and 1
one cup of rice one cup of rice cup of rice and 1
and one cup of and one cup of cup of water
water water
Snacks (if any) None None None
Total Fluid ___mL ___mL ___mL
Intake
ADOL
*ECOMAP Legend:

Family
Strong
Church

Classmates Weak
Patient

J.S.R

Friends

School

Senior Citizen
*ECOMAP Legend:

Famiy
Strong
Church HS Playmate

Weak
Patient
Health Sari-sari
center O.J store

Friends
Friends
CHILD
*ECOMAP Legend:

Family
Strong
Church

Weak
Patient School
Sari sari J.C
store

Friends
ADOL
*7-Day Sleep Diary
Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Hours of Sleep 6 hours 6 hours 6 hours 6 hours 6 hours 10 10
hours hours
Sleeping Time 10:00 10:00 10:00 10:00 10:00 1:00 AM 1:00 AM
PM PM PM PM PM
Waking Time 5:00 AM 5:00 AM 5:00 AM 5:00 AM 5:00 AM 10:00 10:00
AM AM
Bedtime Rituals Praying Praying Praying Praying Praying Praying Praying
Feeling upon Drowsin Drowsin Drowsin Drowsin Drowsin Drowsin Drowsin
waking up ess ess ess ess ess ess ess
Problem NONE NONE NONE NONE NONE NONE NONE
Encountered

SENIOR CITIZEN
*7-Day Sleep Diary
Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Hours of Sleep 7 hours 7 hours 7 hours 7 hours 7 hours 7 hours 7 hours
Sleeping Time 9:00 PM 9:00 PM 9:00 PM 9:00 PM 9:00 PM 9:00 PM 9:00 PM
Waking Time 4:00 AM 4:00 AM 4:00 AM 4:00 AM 4:00 AM 4:00 AM 4:00 AM
Bedtime Rituals Praying Praying Praying Praying Praying Praying Praying
Feeling upon Drowsin Drowsin Drowsin Drowsin Drowsin Drowsin Drowsin
waking up ess ess ess ess ess ess ess
Problem NONE NONE NONE NONE NONE NONE NONE
Encountered

CHILD
*7-Day Sleep Diary
Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Hours of Sleep 6 hours 6 hours 6 hours 6 hours 6 hours 6 hours 6 hours
Sleeping Time 10:00 10:00 10:00 10:00 10:00 10:00 10:00
PM PM PM PM PM PM PM
Waking Time 4:00 AM 4:00 AM 4:00 AM 4:00 AM 4:00 AM 7:00 AM 7:00AM
Bedtime Rituals Praying Praying Praying Praying Praying Praying Praying
Feeling upon Drowsin Drowsin Drowsin Drowsin Drowsin Drowsin Drowsin
waking up ess ess ess ess ess ess ess
Problem NONE NONE NONE NONE NONE NONE NONE
Encountered