NUTRITION AND DIET ASSESSMENT QUESTIONS

NAME: MARIA ANGELA P. DEL GALLEGO

DATE: MARCH 18, 2021 BMR: 1, 323
HEIGHT (cm): 165 CM AGE 19 TDC/TMR: 1905.12
WEIGHT (kg): 89 GENDER FEMALE LIFESTYLE:SEDENTARY
I. GOAL SETTING: WHAT ARE YOUR TOP GOALS RELATED TO HEALTH, NUTRITION, AND FITNESS?
1 LOSE WEIGHT
2 TO HAVE A HEALTHY LIFESTYLE
3 TO BE HAPPY
HOW DETERMINED ARE YOU TO WORK ON ACHIEVING THESE GOALS? (ON A SCALE OF 1-10, WITH10 AS HIGHLY MOTIVATED): 10
II. NUTRITION AND DIET ASSESMENT: Please fill out the blanks
A. DIET AND HEALTH HISTORY
ANY TYPE OF DIET OR DIET PROGRAMS WHICH YOU TRIED IN THE PAST? FASTING
1 WHEN DID YOU START? Jun-20
RESULT:
DURATION OF PROGRAM: 2 MONTHS for the 2 months I have been fasting I can feel like my body became lighter and I lose weight,
ANY TYPES OF DIET OR DIET PROGRAM WHICH YOU ARE CURRENTLY DOING? none
2 WHEN DID YOU START? none
RESULT:
DURATION OF PROGRAM: none none
3 ANY PAST MEDICAL CONDITION THAT SHOULD BE NOTED? none
4 ANY PRESENT MEDICAL CONDITION/S OR HEALTH CONCERN? none
B. MEAL PATTERN AND DISTRIBUTION
WHICH OF THE MEALS DO YOU REGULARLY CONSUME? (CHECK THOSE THAT APPLY)
✘ ✘
BREAKFAST ✘ LUNCH DINNER
AM SNACK PM SNACK MIDNIGHT SNACK
C. EATING HABITS
YOU ALWAYS: (CHECK THOSE APPLY)
✘ EAT ALONE
PREPARE YOUR OWN FOOD
✘ CONSUME FAST-FOOD FOOD ITEMS
✘ EAT OUT IN RESTAURANTS (LOVES FOOD/ WORK-RELATED/ MEETINGS/ SOCIALIZATION)
DRINK ALCOHOL BEVERAGES LIKE: QTY:
EAT MORE THAN USUAL WHEN: (CHECK THOSE APPLY)
HUNGRY
✘ STRESSED

IN RESTAURANTS
OUT W/ FRIENDS
DINNING W/ FAMILY
ON VACATION/ WEEKENDS
D. FOOD PREFERENCES
FOOD LIKES: PROCESSED FOODS, SWEET AN SALTY FOODS
CUISINE:
SPECIFIC FOOD ITEMS: ICE CREAM, BURGERS AND PIZZA FILIPINO, JAPANESE AND CHINESE
FOOD DISLIKES: NONE
FOOD ITEMS AVOIDED: CRISPY PATA REASON FOR DISLIKE:
REASON FOR AVOIDANCE: ITS HAS SO MUCH FATS NONE
E. MEDICATIONS AND SUPPLEMENTS
LIST DOWN ALL THE MEDICATIONS AND SUPPLEMENTS THAT ARE REGULARLY TAKING
VITAMIN C - MULTIVITAMINS