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Appendix I

This document contains an interview schedule and questionnaire to assess the nutritional status of elderly people aged 60-75 years in Coimbatore district. The interview schedule collects personal details, anthropometric measurements, clinical assessment of symptoms related to major organs, dietary assessment of food habits and frequency, and a food frequency questionnaire. The questionnaire contains 22 questions on issues like chewing ability, food and diet preferences, meal patterns, water intake, sleep, vision, breathing, diseases, medication, joint pain, stress, surgery, fatigue, and bowel movements.

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66 views8 pages

Appendix I

This document contains an interview schedule and questionnaire to assess the nutritional status of elderly people aged 60-75 years in Coimbatore district. The interview schedule collects personal details, anthropometric measurements, clinical assessment of symptoms related to major organs, dietary assessment of food habits and frequency, and a food frequency questionnaire. The questionnaire contains 22 questions on issues like chewing ability, food and diet preferences, meal patterns, water intake, sleep, vision, breathing, diseases, medication, joint pain, stress, surgery, fatigue, and bowel movements.

Uploaded by

prabhu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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APPENDIX I

APPENDIX I

INTERVIEW SCHEDULE TO ELICIT NUTRITIONAL STATUS OF ELDERLY


(60-75 YEARS) OF COIMBATORE DISTRICT

PERSONAL DETAILS

Name :

Age :

Sex : a) Male b) Female

Religion : a) Hindu b) Muslim C) Christian d) Other

NUTRITONAL ASSESSMENT

Anthropometric Measurement:

Height :

Weight :

BMI :

IBW :

CLINICAL ASSESSMENT

S.No Organ Symptoms Present Absent


1. Hair a) Easily pluckable
b) Dry
c) Brittle hair
2. Nail a) Transverse lines
b) Spooning
c) Dry
3. Skin a)Pale colour
b)Pigmentation
4. Eyes a) Night blindness
b) Xerosis
c) Conjunctiva
inflammation
5. Mouth a) Glossaries
b) Bleeding gums
c) Angular
stomata’s
d) Inflammation
and cracking of
the corner of
the mouth
e) Loss of the
tooth enamel

6. Neck a) Goiter
b) Parotid
enlargement
DIETARY ASSESSMENT

a) Food Habits:

a) Vegetarian b) Non -Vegetarian c) Ova-Vegetarian

Sl.No Food Daily Weekly Monthly Occasionally


groups
1. Cereals
2. Millets
3. Pulses
4. Fruits
5. Vegetables
a)Roots
and tubers
b)Green
leafy Veg
c)Other
Veg
6. Milk and
Milk
products
7. Nuts and
Oil seeds
8. Meat
9. Fish
10. Chicken
11. Egg
12. Sugar
13. Sweets
14. Junk foods

b)Food frequency (24 hours recall method) :

Sl.No Time Food Quantity


1. Early morning
2. Breakfast
3. Mid morning
4. Lunch
5. Tea time
6. Dinner
7. Bed time
Questionnaire
OLD AGE PEOPLE

1. Will you be able to chew the food properly?


o Yes
o No
2. What type of food do you prefer?
o Vegetarian
o Non-Vegetarian
3. What type of diet do you prefer?
o Normal diet
o Soft diet
o Bland diet
4. Do you have the habit of binge eating?
o Yes
o No
5. How many meals do you consume in a day?
o 2 times
o 3 times
o 4 times
6. Do you skip any meals?
o Yes
o No
7. How many liters of water do you8 consume in a day?
o 1 liter
o 2 liter
o 3 liter
8. Do you follow any special diet?
o Yes
o No
9. Do you have memory loss?
o Yes
o No
10. Do you have proper sleep?
o Yes
o No
11. How many hours do you sleep in a day?
o 6 hours
o 7 hours
o 8 hours
o Less than 6 hours
12. Do you have vision problem?
o Yes
o No
13. Do you have breathing problem?
o Yes
o No
14. Do you have any disease?
o Yes
o No
If yes, what disease?
15. Do you consume any drugs?
o Yes
o No

16. Do you have any leg cramps, joint pain?


o Yes
o No
17. Do you have mental stress?
o Yes
o No
18. Do you have undergone any surgery?
o Yes
o No
If yes, what surgery?
19. Do you feel fatigue often in a day?
o Yes
o No
20. Do you have proper defecation?
o Yes
o No
21. Decreased in taste sensitivity?
o Yes
o No
22. Feeling of dry mouth?
o Yes
o No

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