Name: __________________________ Date:

___________

Section: ________________

ACTIVITY 6: Nutritional Assessment

1. What time did you go to bed the night before last? ______________________

Was this the usual time? _____________________

2. What time did you get up yesterday? _____________________

Was this the usual time? ________________

3. When was the first time you had anything to eat or drink? _________________________

What did you have and how much?

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________

4. When did you eat again? __________________________________

Where? _______________________________

What and how much?

_____________________________________________________________________________________
_________________________________

5. When did you eat next? _____________________________________________

What did you eat and how much?

_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________

6. Did you eat or drink anything else?

a. Anything from 1st to 2nd meal? ________________________

b. Anything from 2nd to 3rd meal? _______________________

c. Anything from 3rd meal to bed time? ____________________

7. Was this day’s food intake different from usual? ________

If so why?
_____________________________________________________________________________________
___________________________________________________________________

8. Is weekend eating different? _______

If so why?
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___________________________________________________________________
 24 HOUR RECALL FORM

Name: __________________________________________________

Date: ________/___________/_______

Day of week (highlight in red font): Sun Mon Tue Wed Thu Fri Sat

Time of meal:

Food or beverage:

Type of preparation:

Amount:

Was this intake unusual? (Put X on blank of chosen answer) Yes ____ No ____

If so how?
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________

Do you take any vitamin or mineral supplement?

Yes ____ No ____

If yes, describe:

Name or type:

Dose (if known):

How often:
 FOOD FREQUENCY QUESTIONNAIRE

1. Do you drink milk? If so, how much? __________________________

What kind? Whole _____Skim ____

2. Do you use fat? If so, what kind? _____________________________

How much? ____________

3. How many times do you eat meat? _________________________

Eggs ______ Cheese ________ Beans __________

4. Do you eat snack foods? If so, which ones? ___________________________

How often? ____________________ How much? __________________

5. What vegetables do you eat? (in each group)

How often? ___________

a. Broccoli __________ Green pepper ____________ Cooked greens ____________ Carrot

___________

Sweet potato ____________

b. Tomato ____________ Raw cabbage ___________ Asparagus ______________ Beets __________

Cauliflower __________ Cooked cabbage __________ Celery ____________ Peas ___________

Lettuce ____________

6. What fruits do you eat and how often?

a. Apples or apple sauce ___________ Apricots ___________ Banana ____________ Berries

____________

Cherries __________ Grape or grape juice ___________ Peaches __________ Pears __________

Pineapple __________ Plums ____________ Raisins ____________

b. Oranges ___________ Orange juice _____________ Grape fruit _____________ Grape fruit juice
________

7. Bread and Cereal Products

a. How much bread do you usually eat with each meal? _______________
Between meals? ________

b. Do you eat cereal? (Daily, Weekly)

Cooked ___________ Dry _____________

c. How often do you eat foods such as macaroni, spaghetti, noodles, and the like? ______________

8. Do you use salt? _____________

Do you “crave” salts or salty foods? ___________

9. How many teaspoons of sugar do you use/day?

(1 packet to 1 teaspoon) ___________

10. Do you drink water? _______

How often during the day? ____________

How much each time? ____________

How much would you say you drink each day? _____________

11. Do you drink alcohol? ___________ How often? _______________

How much? _____________

Beer, wine, others? __________

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