A survey questionnaire use to determine nutritional status of individual

1. NUTRITIONAL STATUS SURVEY
(By P. M. Veroy RN, MAN)
Personal Data:
Name: (Optional)_____________________________________
Age________ Gender_________
Height_________ Weight (Kg) ________
Religion: ( ) R. Catholic ( ) SDA ( ) Islam; Others please specify:_____________________
Directions:
1. Be sure to fill out the questionnaire as accurately as possible and avoid underestimating your food intake.
2. Your food choices should cover the past three (3) months until the present to show what you eat in your
regular meals everyday.
3. Mark check (/) the options that indicate serving per day with each corresponding food classification.
Part A: Daily Food Consumption Survey:
Food Groups Servings Per Day
Vegetables Measure 4-6 2-3 1
I - A Chinese cabbage, alugbati leaves, ampalaya fruit/ leaves,
bamboo shoot, banana heart, cabbage, cauliflower, celery,
chayote fruit/leaves, cucumber, eggplant, gabi leaves,
kangkong, lettuce, malunggay leaves, mushroom, okra,
petsay, radish, saluyot, squash, string beans, tomato, upo,
sitsaro. Seaweed.
1 cup, raw
½ cup, cooked
2 cups, raw
1 cup, cooked
I – B carrot, coconut shoot (ubod), kamansi, langka hilaw,
patani, mungbean sprout (toge), singkamas, cowpea pods,
stringbeans pod.
½ cup, raw
½ cup, cooked
Fruits Measure 4-6 2-3 1
Banana (any kind), mango, pineapple, papaya, watermelon,
jackfruit,
1 whole fruit (for very
large or small chopped) 1
cup
Calamansi, orange, suha, pineapple, mango
In Fruit juice ¼
cup
Fresh buko juice 1/3 cup
Beans and Legumes Measure 4-6 2-3 1
Baguio beans, black beans, garbanzo beans, peas 1 cup cooked
Nuts and Seeds
Peanut, cashew nut ¼ cup
Rice, Grains, Cereals, Breads & Pastas Measure 4-6 2-3 1
Rice, cooked ½ cup, packed

2. Bread (Pan de amerikano, pan de leche, monay, pan de sal)
2 slice or 2 pc.
(average of 6x5x4 cm) n
size
Wheat, oats, noodles, spaghetti, macaroni I cup
Meats and Fish Measure 4-6 2-3 1
Lean meat of beef, pork
1 slice matchbox size
Chicken (hita, laman, pitso)
1 small leg, ¼ breast
(6 cm long), laman,
matchbox size
Food Groups Servings Per Day
Internal Organs / Variety of Meat -
Measure 4-6 2-3 1
Blood (Dugo) – pork, beef, chicken
gizzard (balun-balunan chicken); heart, liver, lungs,
spleen, small intestines, uterus (pork, Beef)
¾ cup
Fish – bangus, matambaka, bariles, tune, lapu-lapu, hito,
galunggong, (large and medium size fish)
1 slice (7x3x2 cm) for big
fish
1 serve average of ( 18-
22x4-5x1/2-1 cm) for
medium fish
- small size; sapsap, tilapia, tamban, dilis ¼ cup
Other Seafoods Measure 4-6 2-3 1
Shrimps (alamang) 1 ¼ tbsp.
Crabs (alimango) 1 tbsp.
Lobster 2 tbsp.
Sea shells (kuhol, susong pilipit, taho, talaba)
2-3 cups with shell or 1
cup shelled
Dairy and Eggs Measure 4-6 2-3 1
Chicken egg / salted duck’s egg 1 pc
Quial’s egg 9 pieces
Cheddar cheese 1 slice ( 6x3x2cm)
Cheese filled 1 slice (6x3x2 ½ cm)
Fresh milk (cow/goat), powdered filled milk 1 cup
Butter, margarine, mayonnaise, cream, gravy, refined sugar,
oil
1 tbsp or sparingly
Part B : Daily Lifestyle Survey
Direction: Mark check (/) your choice of answer on the underlined space before the option.
Tobacco Use:
1. What best describes your use of cigarettes, pipes, and cigars?
____ Never smoked ____ Former smoker ____ Smoker
2. How many sticks or pack(s) consume per day? _______________________________.
Alcohol:

3. 3. Do you drink alcohol? _____No ____ Yes
4. If YES, what type of alcohol? _____ (beer any kind, gin, rum, whisky, brandy)
_____ (tuba, lambanog, grape wine, sioktong)
5. How many glasses of alcohol do you drink per day? _____ 5 glasses or more, _____ 3-5 glasses,
_____ 1-3 glasses, _____on occasion only
Exercise:
6. Do you exercise regularly? ____No ____Yes.
If YES; how many times a week? ____everyday ____ 2-3 times, ___1-2 times
____once a week
7. Duration per exercise; ____1 hour or more, ___45mins.-1 hour, ____ 30-45 minutes,
____ 15-30 minutes
8. Type of exercise: ____Jogging, _____aerobic work-out, _____biking, ____swimming, ____weight lifting,
others please specify:______________________________________
Water Intake:
9. How much glasses of plain water do you consume daily? ____10-12, ____ 8-10, ____ 6-8, _____ 5 or less
Waste Elimination:
10. How often do your bowels eliminate? ____twice daily, ____once daily, ____3-4 times a week,
____once or twice a week only
Sleeping Habit:
11. How many hours you usually sleep a day? ____8-10, ____6-8, ____4-6, ____less than 4 hours.
12. What type of sleeping pattern? ____ Continuous at night time, ____ With 3 or more wakes in between sleep
at night time, ____irregular frequency at any time of the day,
Nutritional Supplement:
13. Do you take nutritional supplement? ____ No, ____ Yes.
If YES, which type? ____ vitamins/minerals, ____ amino acids, ____ herbs.
14. How often do you take it? ____ 2 times or more per day, ____ once daily, _____ every other day,
____ 2-3 times a week.
Part C: Food Eating Habits Survey:
Direction: Mark check (/) your choice of answer on the underlined space before the option.
1. How many times a week do you eat breakfast, lunch, or dinner in a RESTAURANT or FAST FOOD PLACE?
(Include all food prepared away from home, such as take-out food and home delivered food and ready-to-
eat or deli food to take home. Do not include brown bag meals prepared at home.)
___ Never eat out, ___ 1-3 times per week, ___ 4-6 times per week, ___ 7 or more times
Hunger:
2. How hungry do you usually feel BEFORE you eat meals or snacks?
MEALS SNACKS
___Do not eat meals ___Do not eat snacks
___Not at all hungry ___Not at all hungry
___A little hungry ___A little hungry
___Neither hungry or full ___Neither hungry or full
___Moderately hungry ___Moderately hungry
___As hungry as I have ever felt ___As hungry as I have ever felt
3. How full do you usually feel AFTER you eat meals or snacks?
MEALS SNACKS
___Do not eat meals ___Do not eat snacks
___Not at all full ___Not at all full
___A little full ___A little full
___Neither hungry or full ___Neither hungry or full
___Moderately full ___Moderately full
___As full as I have ever felt ___As full as I have ever felt
Food Frequency:

4. 4. How often do you eat HIGH FAT MEATS such as marbled or untrimmed beef, beef, pork, hamburger meat,
poultry with skin, sausage, hotdogs, bologna, longaniza, chorizo, tocino and salami?
____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never
5. How often do you eat FRIED FOODS such as French fries, fried meat, fried poultry, fried fish, potato or corn
chips, fried vegetables, or fried cheese?
____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never
6. How often do you use BUTTER or STICK MARGARINE with your food?
____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never
7. How often do you eat HIGH-FAT BAKED FOODS such as biscuits, cornbread, croissants, waffles, or
pancakes? (Sweet baked muffins and cookies, not included)
____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never
8. How often do you eat HIGH-FAT CONVENIENCE FOODS such as regular frozen dinners, entrees, or frozen
pizza?
____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never
9. How often do you eat HIGH SALT SNACKS, such as popcorn, high-fat crackers, potato chips, salted dried
peas, peanuts, corn, and other snack mixes?
____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never
10. How often do you eat HIGH-FAT, HIGH SUGARED FOODS such as ice cream, puddings, cakes, muffins,
cookies, pies, doughnuts, or chocolate candy?
____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never
11. How often do you eat HIGH-SUGAR FOODS that are low-fat or fat-free such as desserts, cookies, frozen
yugort, regular drinks, and hard candy?
____daily, ____1-6 times per week, ____ 3 times per month or less, ____seldom or never
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Pmv-12-27-06