Questionnaire Number: ______

BACKGROUND INFORMATION
1 (Son/Daughter) Name
(Surname, Given Name, MI)

2 (Mother)

3 (Father)

Gender Birthdate (Month, Day, Year) Age (Years) Year/Course (if studying) Occupation (if working) Present City/Town of Residence Present Province of Residence Years Living in Present Residence
* Present residence refers to house where one stays more than 50% of the time during a typical week.

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Anthropometric Measures:
Weight (Kg) Height (m) Bideltoid (cm) Biacromial (cm) Shoulder (cm) Chest (cm) Waist (cm) High Hip (cm) Hip (cm) Triceps skin fold Upper Arm Length Upper Arm Circumference Lower Arm Length Lower Arm Circumference Elbow Breadth

Identify Body Type:

1 2 3
Endomorph thin, linear appearance narrow waists, hips, and shoulders tend to have low levels of body fat have a hard time gaining lean muscle mass lose weight easily Mesomorph have an athletic build broad shoulders & a narrow waist have a fast metabolism
gain muscle mass easily

have big bones round faces with large thighs & hips high waist Ectomorph stocky appearance Weight loss is most difficult high levels of body fat small hands and feet have arms and legs that tend to be short and tapering

Upper Leg Length Upper Leg Circumference Lower Leg Length Lower Leg Circumference Kneecap width

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Identify Body Shape:

Identify Body Shape:

Narrow waistline Large bust and broad hips Hour Glass

Pear/Spoon/Bell Shape Body Triangle Fuller bottom and legs Broad hip/buttocks hips slightly wider than shoulders tend to gain weight below waist small chests and flat stomachs larger lower bodies and smaller upper bodies

Bust and hips almost same Bust & hips differ around 1inch only Waist is 25cm less than hips Waist is 25cm less than bust Figure envied by females Tend to gain weight all over body Easily increases chest size Easily increases hips
Waist smaller than hips

Trapezoid Shaped Body tent to gain weight along the backside

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Identify Body Shape:

Identify Body Shape:

Apple/Rounded Shape Body Big belly or abdomen Oblong Wide waist Stomach wider compared to hip Arms and legs short slim hips & a large chest & stomach tend to gain weight above the waist bigger on the top half of their bodies than on the bottom half

Inverted Traingle V Shaped body Tulip Shaped Body Broad shoulders Flat bottom and slim legs Muscular Large bones Thigh and hips smaller than bust and shoulder

Inverted Trapezoid Body

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Identify Body Shape:

Identify Body Shape:

Pencil Shaped Body Columnar Shaped Body Slim figure Long legs maintain slender arms and legs put on weight in their stomach and backside Same shoulder and hips Waist near value of hips and bust no large difference in size of their hips, waists, and shoulders

Wide Rectangle Stocky Big built Boyish Shape Tendency to gain weight Large arms and legs

Slim Rectangel

Identify Body Frame/Built

Large/Big (Bones) Medium (Bones) Small (Bones)

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Lifestyle
How would you characterize your How would you characterize your In your opinion, what is your Level of diet in terms of PROTEIN intake? diet in terms of fat intake? Activity: Active Semi-active Moderate Semi-sedentary Sedentary (little or no physical activity)

3
How would you characterize your How would you characterize your How would you characterize your diet in terms of SUGAR intake? diet in terms of FIB ER intake? diet in terms of CARBOHYDRATE intake?

Lifestyle
Low (Nearly all the time) Low (Most of the time) Moderate (Most of the time) High (Most of the time) High (Nearly all the time) Low (Nearly all the time) Low (Most of the time) Moderate (Most of the time) High (Most of the time) High (Nearly all the time) Low (Nearly all the time) Low (Most of the time) Moderate (Most of the time) High (Most of the time) High (Nearly all the time)

Low (Nearly all the time) Low (Most of the time) Moderate (Most of the time) High (Most of the time) High (Nearly all the time) Low (Nearly all the time) Low (Most of the time) Moderate (Most of the time) High (Most of the time) High (Nearly all the time)

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Lifestyle
How would you characterize your diet in terms of SALT intake? Low (Nearly all the time) Low (Most of the time) Moderate (Most of the time) High (Most of the time) High (Nearly all the time)

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