Food Survey

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NUTRITIONAL ASSESSMENT SHEET

 Personal history

Names last names:


Sex: Age: Ruth:
Civil status: Forecast type:
Scholarship: Occupation: Physical activity:
Tobacco Alcohol Drugs
Other illegal drugs
Current illness
Date of admission: / / .
Birthdate: / / .
Entry Time: _________

 Medical and Clinical History

Morbid Family History


Obesity Cancer
Mellitus diabetes Dyslipidemia
Arterial hypertension Anemia
Others:

Morbid Personal History


Diagnosed diseases Mellitus diabetes
Arterial hypertension
Gastric ulcer
Respiratory diseases
Food allergies
Alimentary intolerance
Drug Allergies:
Medication use Diuretics Antihypertensive
Laxatives Antacids
Analgesic Antidepressant
Gastrointestinal Information Constipation Nausea
Diarrhea Threw up
Gastritis Pyrosis
Sore Colitis
Depositions Type of Number of
bowel bowel
movements movements
Gynecobstetric History last menstruation
Pregnancies Ye No How
ah many
Contraceptives Ye No Which
ah
Type of Birth Normal Caesarean section
 Nutritional History

 Have you had any special diet_____________________ How many____________


 Time_________________ Reason_________________________________
 Results_________________________________________________________
 Use of medications to lose weight YES___ NO___ Which_________________

What was your first meal of the day? Do you season your foods?

Service Hou Y No Y No
r e e
a a
h h
Breakfast Natural seasonings
Lunch Table salt
Eleven Oil
Dinner
Collations

24-hour Food Survey


Hour Service Food Amount Guy

Breakfast

Lunch

Eleven

Dinner
Collations

Food Survey by Frequency of Consumption


Food Guy Frequency Portion Preparation type
Day Week Mon
th
Dairy AG
GM Dairy
BG Dairy
Beef
Pork and cold cuts
Chicken
Lamb
Viscera
Fish
Seafood
Eggs
Legumes
Potatoes
Vegetables
Fruit
Rice
Oatmeal
Pasta
Bread
Oil
Butter
Mayonnaise
Cream
Sugar
Alcoholic beverages
carbonated drinks
powdered juices
Candies
Water
Salt

QUESTIONNAIRE
 Have you had any special diet_____________________How many_____________
 Time_________________ Reason_________________________________
 Results_________________________________________________________
 Use of medications to lose weight YES__ NO___ Which__________________
 How many meals do you eat per day:____
o At home_________________________________
o Out__________________________________
 Who prepares your food:_________________________________________
 Favorite foods:_______________________________________________
 Foods you don't like:_______________________________________________
 Foods that cause discomfort:_____________________________________
 What time are you most hungry___________________
 Take some type of supplement:

 YES ___ NO ___ Which______________________ Dose_________ Why_________

 Addition salt: YES___ NO ___


 Type of fat used for cooking: Oil__ Butter__ Seed oil__ Other________
 Natural water consumption (glasses per day)________________________________
 Consumption of beverages per day (milk, broths, soups...)_______________________
 Your number of intakes varies depending on your mood: Sad___ Nervous___
 What foods do you eat at that time______________________________
 Do you go to the bathroom regularly? BUT___
 Fiber supplement YES___ NO____
Which________________________________________
 Type of cooking most frequently used:
a. Frying___
b. Oven___
c. Iron___
d. Steam___
e. Ember___
f. Microwave____

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