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Questionnair Print Patients One

This document contains a 24-hour food consumption recall questionnaire to collect dietary information from subjects. It includes sections on demographic profile, clinical examination, dietary information, and a table to record food/beverages consumed at different times of the day over a 24-hour period including breakfast, snacks, lunch, dinner, and late night snacks. The goal is to gather data on the subject's food intake, eating habits, nutritional status, and activity level over a full day.

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sajjad khan
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49 views4 pages

Questionnair Print Patients One

This document contains a 24-hour food consumption recall questionnaire to collect dietary information from subjects. It includes sections on demographic profile, clinical examination, dietary information, and a table to record food/beverages consumed at different times of the day over a 24-hour period including breakfast, snacks, lunch, dinner, and late night snacks. The goal is to gather data on the subject's food intake, eating habits, nutritional status, and activity level over a full day.

Uploaded by

sajjad khan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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24 Hrs FOOD CONSUMPTION RECALL QUESTIONNAIRE

DEMOGRAPHIC PROFILE:
ID NO:…………….

1 Name of subject
2 Gender
3 Age _____ years

4 Ethnicity Muslim_____ Non-Muslim______

5 Educational Status Illiterate_____ Primary-Middle______


Undergraduate____ Graduate_______
Postgraduate______ Any other_____
6 Living area Urban______ Rural_________

7 Family setup Nuclear___________ joint____________

8 Total family members

8 Income from all sources _________________per capita

9 Work/job
12 Contact Number
13 Address:

CLINICAL EXAMINATION:

S.N Anthropometric measurements


O
1. Weight (kg)

2. Height (cm)

3. MUAC (cm)
4. General assessment

Sr.# Clinical signs and symptoms

1. Pallor

3. Dry skin
4. Edema
5. Brittle hair
6. Weight loss in past 3 months
7. Any other

1
DIETARY INFORMATION:

1 Do you take meals Regular Irregular


regularly? (3times/day) 
(not on time)
2 Do you take breakfast? Daily 3-4time/wk 1-2time/wk Not at all

3 How many times you Two Three Four to Five


take meal/day?
4 Do you get adequate food Yes: No:
to eat every day?

5 How often do you take Daily 3-4time/ wk 1-2time/wk Not at all


snacks apart from meals?
meals?
6 How many times do you
take vegetables?
7 How many times do you
take fruits & fruit juices?
8 How many times do you
take meat?
9 How many times do you
take milk?
10 How many times do you
take milk products?
11 How many times do you
take cereals?
12 Supplements consumed?

13 Activity level? sedentary mild moderate Hard

14 Type of activity?(e.g.
walking, jogging,
swimming, cycling, gym,
others)
15 Total duration of
physical activity?

Others

24 Hrs FOOD CONSUMPTION RECALL QUESTIONNAIRE:

2
Date: _________________

Time of Food/water/beverages Quantity/ amount Cooked/ Place of food


the day consumed consumed uncooked consumption

Breakfast

6am to
9am

Snacks

09:15am
to
11:30am

Lunch

11:45am
to
03:30pm

3
Snack

4pm to
6:30pm

Dinner

7pm to
9:30pm

Late
night
snack

9:45pm
11:30pm

Others

From
11:45pm
to 6am

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