Sex

Male
Female

1
2

Religion
Roman Catholic
Iglesia ni Cristo
Mormon
Islam
Protestantism
Others

1
2
3
4
5
6

BMI Interpretation
Normal
Overweight
Obese
Underweight
Severly underweight

1
2
3
4
5

Water Intake
<3 glasses per day
4-7 glasses per day
8 glasses per day
Drinking Water Source
Deep well
Local Water System
Others
Hygienic Practices
Hand washing at critical times
Presence of permanent HW stations
Bathing Frequency
1-3x per week
4-6x per week
Every day

Nutritional History

Oral Hygiene

Seldom
Every 3 months
1-2x per month
1-3 days per week
4-7 days per week

1
2
3
4
5

Meal Frequency per day

1/day
2/day
3/day
>3/day

1
2
3
4

Less often
Once a day
2-3x per day

1
2
3

ource
1
2
3
Yes
1
1

ncy
1
2
3

1
2
3

No
0
0

F1.1

F1.2

F1.3

F1.4

First Name

Last Name

Date of Birth

Age

F1.5

F1.6

F1.7

Sex

Religion

Education

F1.8
Address

A1.1

A1.2

A1.3

A1.4

Weight

Height

BMI

Interpretation

A1.5

A1.6

A1.7

B1.1

B1.2

Temperature

Heart Rate

Respiratory Rate

Rice

Fish

B1.3

B1.4

B1.5

B1.6

B1.7

Meat and Poultry

Vegetables

Fruits

Milk Products

Seafood

B1.8

B1.9

B1.10

B1.11

B1.12

Processed Foods

Canned Goods

Noodles

Junk Foods

Others

B1.13

B2

B3

Interviewer Comments (Indicate other food types)

Meal Freq./day

Water Intake

B4

C1.1

C1.2

Drinking Water Source

HW at Critical Times

Permanent HW stations

C1.3

C1.4

Bathing frequency

Oral Hygiene

D1
Interviewer Comments (Chief Complaint / Pertinet Findings)