Clinical Instructor
Nutritional Status and Practices
QUESTIONNAIRE
Part I: PERSONAL AND ANTHROPOMETRIC INFORMATION
Instructions: Please answer the following.
Name (Optional): ________________________________________
Age: __________Sex: __________
Civil Status: ❐Single ❐Married ❐Widowed ❐Separated
Religion: ____________________________
Weight (kg): _____________Height (m): _____________BMI: _______________
Living Arrangement:
❐Alone ❐With Family ❐Owned House ❐ Renting an apartment ❐ Staying at boarding house
Health Conditions:
Present Diagnosed Illness _________________________
Nutritional Related Illness: _________________________
List any allergies you have (food) ______________________________
List any medications you are currently taking_______________________________________
List any surgeries you have had and the year were performed:
__________________________________YEAR:____________________________________
__________________________________YEAR:____________________________________
__________________________________YEAR:____________________________________
Do you follow special diet? ❐NO ❐Low fat ❐low sodium ❐kosher ❐diabetic ❐vegetarian
Others, please specify_________________________________
Part II.
A. Food Intake and Source
FOOD RECALL
Instruction: Recall 24 hour food intake during an RLE day, ordinary school day and a weekend. Please
specify the day and date on the blank provided.
During RLE Duty Days Date _____________________
Food Item Serving Size Time Consumed Where/Source of food
Breakfast
Snack
Lunch
Snacks
Supper
Midnight Snack
During Ordinary School Day Date _____________________
Food Item Serving Size Time Consumed Where/Source of
food
Breakfast
Snack
Lunch
Snacks
Supper
Midnight Snack
During Weekends Date _____________________
Food Item Serving Size Time Consumed Where/Source of food
Breakfast
Snack
Lunch
Snacks
Supper
Midnight Snack
B: Eating Habits
Instruction: Please put a (/) check mark on the box, or encircle the letter corresponding to your answer.
1. What meals do you usually skip most? ❐Breakfast ❐Lunch ❐Dinner ❐NONE
2. How many glasses of water do you consume in a day?
a. One glass a day
b. 2-4 glasses a day
c. 5-10 glasses a day
d. 20 glasses a day or more
3. Do you drink coffee? ❐ No ❐ Yes? (How many cup of coffee do you consume each day?)
a. one cup
b. 2-4 cups
c. 5-10 cups
d. 20 cups or more
4. Do you put sugar in the coffee? ❐ No ❐ Yes (how many?) ______________
a. 1 teaspoon
b. 1 tablespoon
c. 1 ½ tablespoon
d. Or more
5. Do you put milk or creamer in the coffee? ❐ No ❐ Yes (How many?) ______________
a. 1 teaspoon
b. 1 tablespoon
c. 1 ½ tablespoon
d. Or more
6. Do you drink juice? ❐ No ❐ Yes? (How many glass of juice do you consume each day?)
a. one cup
b. 2-4 cups
c. 5-10 cups
d. 20 cups or more
7. Do you drink milk? ❐ No ❐ Yes? (How many cup of milk do you consume each day?)
a. one cup
b. 2-4 cups
c. 5-10 cups
d. 20 cups or more
8. Do you drink tea? ❐ No ❐ Yes? (How many cup of tea do you consume each day?)
a. one cup
b. 2-4 cups
c. 5-10 cups
d. 20 cups or more
9. Do you drink soda? ❐ No ❐Yes (how many bottle/can of soda each day?) ______________
a. One bottle/can
b. 2-4 bottles/can
c. 4-6 bottles/can
d. Or more
10. What other beverages do you consume?(please specify) ___________________________
11. Do you eat bread? ❐ No ❐Yes (how many bread do you consume in a day?)
A. one bread
B. 2-4 bread
C. 5-10 bread
D. Or more
12. Do you routinely use butter or bread products such as toast, bagels, etc.
❐ No ❐Yes (how many times?)
a. Once a day
b. 2-3 times a day
13. How often do you eat meat per week?c. 4-6 times a day
d. Or more
a. Once a week
b. 2-3 times a week
c. 4-6 times a week
d. Or more
14. What type of meat do you prefer?
❐ Pork ❐beef ❐chicken ❐cara beef ❐others pls. specify__________________
15. How is it cooked?
( ) grilled ( ) baked ( ) fried ( ) or other please specify _________________________
16. Do you eat luncheon meats, processed meats, sausages, bacon, bologna or any other nitrate salt
containing meat once per week or more on average? ❐Yes ❐ No
How often? _____________________
a. Once a week
b. 2-3 times a week
c. 4-6 times a week
d. Or more
17. How often do you eat poultry products?
a. Once a week
b. 2-3 times a week
c. 4-6 times a week
d. Or more
18. What is your weekly whole egg consumption on average?
a. Less than 2 eggs per week
b. 2-4 eggs per week
c. 5-7 eggs per week
d. 8-11 eggs per week
e. 12 or more eggs per week
19. How often do you eat fish?
a. Once a week
b. 2-3 times a week
c. 4-6 times a week
d. Or more
20. Do you eat barbecued foods that are charred? ❐ Yes ❐ No
How often? _____________________
a. Once a day
b. 2-3 times a day
c. 4-6 times a day
d. Or more
21. Do you consume citrus fruits? ❐ Yes ❐ No
How often? ____________________
a. Once a day
b. 2-3 times a day
c. 4-6 times a day
d. Or more
22. How many servings of fruits?
❐1 serving
❐2-4 servings
❐5-10 servings
❐or more
23. Do you routinely use butter for cooking or on baked potatoes or vegetables?
❐ No ❐ Yes (how many times?)
a. Once a day
b. 2-3 times a day
c. 4-6 times a day
d. Or more
24. Are you a vegetarian or near vegetarian? If yes, please describe
(i.e., vegan, lactovegetarian, etc.) ❐ No❐ Yes _____________________________
25. Do you eat junk foods? ❐ No❐ Yes (what kind of junk foods?)
❐potato chips
❐corn chips
❐vegetarian chips
❐others please specify________________
26. How often, on average, do you consume any high fat snack foods (like: potato chips, nachos, any
fried chips, cheesiest, etc.?)
a) 0-1 times per week
b) 2-3 times per week
c) 4-6 times per week
d) 7 or more times per week
27. Do you eat chocolates? ❐ No ❐ Yes (what kind of chocolates?)
❐sugar free chocolate
❐dark chocolate
❐milk chocolate
❐others please specify_______________________
28. How often, on average, do you consume any sugary carbohydrate snacks and drinks (e.g.,
regular soft drinks, licorice, jujubes, hard candies, gummy bears, etc.?)
a) 0-1 times per week
b) 2-3 times per week
c) 4-6 times per week
d) 7 or more times per week
29. What is your average alcohol consumption?
A.1-3 drinks per day
B. 2-3 drinks per week
C. 3 or more drinks per day
D. 2-3 drinks per month
E. none
30. Do you take nutritional supplements? ❐ Yes ❐No
(Please specify all vitamins, herbs, nutritional supplements) _________________________
