CEBU INSTITUTE of TECHNOLOGY - UNIVERSITY Cebu City NUTRITION HISTORY Name of Respondent Mt: Date Interviewed _!!/> age _Sex_£ Height 12 “au _ Weight __41 d 1, How many meals and snacks do you eat each day? Meals snacks 2 How many times a wee, do you eat the follwing meals from home? Breakfast_(p Lunch _2 Dinner _>y What types of eating places do you frequently visit? (check al that apply) Fast food_/ Diner/cafeteria_ Restaurant Other_punghe 2 3. Onaverage, how many pieces of fruit or glasses of jucle do you at or drink each day? Fresh fruit W{A juice (82. cup) 4. Omaverage, how many servings of vegetables do you eat each day? ay 5. On average, how many times a woek do you eat a high fiber breakfast cereal? [A 6. How many times as week do you eat red meat (bee or pork? ae 7. How many times a week do you eat chicken? ax 8, How many times a week do you eat fish or shellfish? x 8, How many hours of televsino do you watch everyday? la Do you usually smack when watching television? Yes aZ_No_ 10. How many times a week do you eat desserts and sweets? EN 11. What type of beverages do you usually dink? How many servings af which do you drink @ day? Water @qlunsirs ik Aleohel ule Whote mak Beer Soda 24 ilk Wine Diet soda 4 1%6 milk Hard iquor__ Sports drink Shim il Iced tea _1ginses Iced tea with sugar Name of Interviewer _katying Lon ale: Yr. & Sec. hs 2 - Date of Interview Poet 24, 292