Nutrition Education: Senior BSND Batch 2016
LEVEL 1 NUTRITION SCREENING FORM
List Supplements/Medicines Taken:
Education HS College
Civil Status S M Widow
UW N OW OB 1, 2, 3
BMI is ______
Waist ____ WC= Hips _____
WC: At Risk
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,
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.)
Congratulations! You already follow a healthy lifestyle. Keep up the good habits
and keep looking for ways to improve.
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.
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
NAME OF STUDENT
A – Anthropometric