HNF 122 Case Study Questionnaire

By:
Ermac, Sophia Anne L.
Marquez, Stephanie C.

Name:
Age:
Gender:
Religion:
Home address :
Current address:
Height:
Weight:
BMI:
Nutritional status:
Waist/ Hip circumference:
Food Likes :
Food Dislikes:
Allergies:
Family and Personal medical history:
Budget for food:

Questions:
1. What time do you usually wake up and sleep?
2. Do you have any vices? If yes, such as what?
3. How many meals do you eat everyday?
4. What are your usual meals (breakfast, lunch, and dinner)?
5. Do you exercise daily?
6. Describe your usual amount of physical activity (Sedentary, Light, Moderate, Active)
7. What are the factors you consider in choosing food or food items?
8. How would you describe your current diet?
9. What nutrition changes or diets have you tried before?
10. Do you take any medications?
11. Do you take supplements or multivitamins?
12. Have you had any illnesses in the past months? Please Identify
13. Were you hospitalized due to illness in the past months?

CLASS SCHEDULE
 TIME MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

7:00-8:00

8:00-9:00

9:00-10:00

10:11:00

11:00-12:00

12:00-01:00

01:00-02:00

02:00-03:00

03:00-04:00

04:00-05:00

05:00-06:00

06:00-07:00