Nuted screening
Pediatric
Adult
Student
Faculty
Support Staff
Others________
Nutrition Education: Senior BSND Batch 2016
LEVEL 1 NUTRITION SCREENING FORM
DATE: ______________
Last Name
Height (meters)
First Name
Middle Name
Age
Address
Constipated YES
NO
Medical Conditions:
List Supplements/Medicines Taken:
YES
Venue: _______________________________
NO
1.
2.
3.
4.
5.
6.
7.
8.
Education HS College
Masters Doctoral
Civil Status S M Widow
UW N OW OB 1, 2, 3
Male Female
Weight (kg)
BMI is ______
Gender
BP
Waist ____ WC= Hips _____
WC: At Risk
WHR =
WHR: At Risk
If YES how many years have you been constipated?
Are You Having a Healthy Lifestyle?
I do aerobic exercises (e.g., fitness walking, jogging, aerobic dance, cycling, swimming,
Zumba, etc.) for at least 20-30 minutes for five or more times per week.
I eat a good breakfast every day (fruit, protein dish, bread/rice, beverage)
I seldom snack between meals on “junk foods” (e.g., chips, doughnuts, soda pop, cookies,
etc.)
I never smoked.
I always or nearly always get at least 7-8 hours of sleep daily.
I never drink alcoholic beverages.
I achieve or maintain a healthy body weight (not too thin; not overweight or obese)
I can manage stress ( no stress-related symptoms like headaches,ulcers, palpitations etc.)
Wellness Recommendations:
6-8 Yes
Congratulations! You already follow a healthy lifestyle. Keep up the good habits
and keep looking for ways to improve.
4-5 Yes
You still have away to go. You are following some of the good health practices.
For better health and longer life, more effort is needed to improve the diet and
increase your physical activity level.
0-3 Yes
You cannot follow most of the good health practices. A more detailed lifestyle
modification is all you need. Please contact the Nutrition Clinic for further
professional advice.
____________________________
NAME OF STUDENT
NUTRITIONAL ASSESSMENT:
A – Anthropometric
B- Biochemical
C- Clinical
D- Dietary
E- Ecological
…
