MEAL PLAN QUESTIONNAIRE

Personal Information

Name: Rufina S. Gatchalian____________________________ Gender: Female

Age: 57 Date of Birth: November 6, 1963 Religion: Roman Catholic

Occupation: Housewife Marital Status: Married

Email Address: riogatchalian07@gmail.com Contact Number: 0997-378-9160

Health and Lifestyle Information

Height: 5’4 Current Weight: 77kg BMI (kg/m2): _____________________

Smoking (specify frequency and how many sticks per day): No

Alcohol Drinking (specify frequency and how many drinks per day): No

Exercise Routine (specify frequency, intensity and type of exercise):

____________________________________________________________________________

Medical History (check all that applies)

 Diabetes, specify type: Yes, not known yet Current Medications

 Thyroid Disease, specify _______________ Insulin (2x/day)
 Hypertension
 High Cholesterol: Yes
 Arthritis/High Uric Acid
 Heart Diseases, specify ________________
 Stroke
 Urinary Infection: Yes
 Kidney Disease, specify ________________
 Cancer, specify _______________________
 Asthma
 Others, specify _______________________
____________________________________

Nutrition Information

TYPICAL FOOD INTAKE

 Estimated Amount
Menu/Dish/Food Eaten
Meal/Time (how many cup,
Eaten (rice/bread/pasta, meat, vegetables, fruit, dessert,
tablespoon, teaspoon,
drinks)
glass?)

Rice
Breakfast 1 cup
Meat & vegetables

AM Snack

Rice

Lunch Meat & vegetables 1 Cup

PM Snack

Dinner
 Rice

Meat & vegetables

Midnight
NA
Snack

Food Preferences/Likes/Favorites:

____________________________________________________________________________

____________________________________________________________________________

Food Dislike/Avoidance:

Raw meat like sushi____________________________________________________________

____________________________________________________________________________

Food allergies/intolerance (specify all):

NA__________________________________________________________________________

____________________________________________________________________________

How many meals eaten daily? 4 times How many snacks? 1

How often do you eat out? _____________ What type of restaurants? ____________________

Supplements Taken:

____________________________________________________________________________

Current Diet
Regimen:____________________________________________________________________