I.

NUTRITIONAL STATUS AND DIETARY INTAKE

Name/Code: _____________________________ Age: _________ Sex: _____________ Date: _________________

Height: _______________ Weight: _____________ BMI: ___________________
Present Conditions affecting intake or absorption: __________________________
Food Allergies: _________________________________________
Family History of Diabetes Mellitus: _________________________
Laboratories (If there are any): Latest CBG_________________ Latest HbA1c: _______________________

A. 24-Hour Food Recall Form Day of the Week: _________________

Amount/
Meal Type/Time Name of Cooking Where
Description Brand Size/
of Eating Dish/ Menu Method Prepared
Measure
Indicate if it is Write down the Boiled; fried; Give a detailed description Specify brand Bought food
breakfast, lunch, food eaten in sautéed; broiled; of each food items in terms (Carinderia/restaurant/
supper, am/pm the past 24 hour scrambled; raw; of variety, color, parts, local fast food); given; own
snack or midnight and include others names, form, kind or other produced –
snacks. Record also meals eaten characteristics that will garden/livestock; caught
the time the meal outside identify the food item. from natural sources
was eaten.

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B. Descriptive qualitative Food Frequency Questionnaire (FFQ)
Mark with an ‘X’ the frequency with which you consumed the food recorded.
FREQUENCY
FOOD ITEMS NEVER SELDOM (LESS 1-3 PER 1-2 PER 3-4 PER DAILY
THEN ONCE A MONTH WEEK WEEK
MONTH)
1. Grains and products
Cooked rice
Corn
Native rice cakes and delicacies
Corn chips
Others
2. Root crops and products
Boiled root crops
Potato chips
French fries
Cassava cake
Others
3. Noodles
Noodles and pasta
Instant Noodles
Others
4. Cereals
Breakfast cereals
Instant oatmeal
Cereal drinks
Fortified cereals
Others
5. Breads
Loaf bread and related products
Others
6. Egg
7. Meat, white
Chicken
Fish
8. Meat, red
Beef
Pork
9. Milk and related products

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 Milk (powdered or liquid fresh)
Soya Milk
Chocolate flavored milk
Evaporated Milk
Cheese
Ice cream
Others
10. Fermented food products
Yakult
Yogurt
Tausi (fermented black soy beans)
Miso (fermented soy bean paste)
Fermented viand
Others
11. Fruits
Various types of fruits
Fruits juice
12. Green and leafy Vegetables
Various types of vegetables
13. Sugary foods
chocolates
Others
14. Beverages
Soda
Powdered juices
Flavoured green tea
Others

References:
• FAO. 2018. Dietary Assessment: A resource guide to method selection and application in low resource settings. Rome
• Ganji, V., Abu-Dbaa, R., Othman, H., Zewein, M., Al-Abdi, T., & Shi, Z. (2020). Validation of Vitamin D-Specific Food Frequency Questionnaire against
Food Records for Qatari Women. Foods, 9(2), 195. https://doi.org/10.3390/foods9020195
• Leah, Cecile & Bayaga, Cecile & Pico, Marietoni & Bongga, Demetria & Barrios, Erniel & Gabriel, Alonzo. (2019). Development and Evaluation of a Culturally
Sensitive Food Frequency Questionnaire for the Assessment of Prebiotic and Probiotic Intake of
• Urban-living, Low-to-medium-income Women. Philippine Journal of Science. 148. 551-561.

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II. LEVEL OF PHYSICAL ACTIVITY
Check (√) the box to where your level of activities apply.

LEVEL OF PHYSICAL ACTIVITY NEVER SELDOM (LESS 1-3 PER 1-2 PER 3-4 PER DAILY
THEN ONCE A MONTH WEEK WEEK
MONTH)
1. Light intensity
activities are those that require standing up and moving around,
either in the home, workplace or community. Some examples
include:
• Housework like hanging out the washing, ironing and
dusting
• Working at a standing workstation.
2. Moderate intensity
activities require some effort but you can still talk while doing
them. intensity activities include:
• Brisk walking
• Recreational swimming
• Social tennis
• Cleaning the windows at home.
3. Vigorous intensity
activities lead to harder breathing, or puffing and panting
(depending on your fitness). Examples of vigorous intensity
activities include:
• Aerobics / jogging
• Many competitive sports
• Lifting, carrying and digging.
4. Sedentary behavior
refers to time spent sitting or lying down (except when sleeping),
with very little energy expenditure. sedentary activities include:
• Sitting at work, watching TV
• Reading/sewing/
• Computer use for non-active games or social networking
• Sitting in a car, train, bus or tram.
Reference:
http://healthyweight.health.gov.au/wps/portal/Home/get-informed/physical-activity-and-sedentary-behaviour/levels-of-physical-activity-
intensity/!ut/p/a1/jZDBDoIwDIafhQdYVgYBPCIYNyNcjBF3MVOnLMFB2CTBpxe5GpGe2uT70vbHHBeYa9Gpu7Cq1qL6zDw4UbJaucR32TrYJMDCKI-
y3CU7zxuA4wAk65j64RYA_IgAS5c0DRcZAAvm-
fCjYvjnb2YsIG2WZHfMG2FLpPStxkVT9kZdRIXExapO2R4JfUVGXqW2ou3RWZZDDPWzxUUlO1kZVN_Qt6S0ldoMHT5gPl4ylcQITLzaPPbFa0tBxY7zBl
WAShY!/dl5/d5/L2dBISEvZ0FBIS9nQSEh/

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 III. Provide five (5) personalized health teachings to the client according to the nutritional and physical level
assessment.

Name/Code: _____________________________ Age: _________ Sex: _____________ Date: _________________

Height: _______________ Weight: _____________ BMI: ___________________
Present Conditions affecting intake or absorption: __________________________
Food Allergies: _________________________________________
Family History of Diabetes Mellitus: _________________________
Laboratories (If there are any): Latest CBG_________________ Latest HbA1c: _______________________

HEALTH TEACHINGS:

1. _____________________________________________________________________________________________

2. _____________________________________________________________________________________________

3. _____________________________________________________________________________________________

4. _____________________________________________________________________________________________

5. _____________________________________________________________________________________________