NUTRITION MANAGEMENT SERVICES

FOOD RECORD SURVEY FORM

PATIENT NAME
LAST NAME

BIRTHDATE
FIRST NAME

MIDDLE NAME

ADDRESS

FOOD ALLERGIES: Yes

1.

2.

3.

4.

5.

MM

DD

PLACE BARCODE
STICKER HERE

YYYY

RELIGION

No

If yes, please specify:

Where you take your meals during weekdays?

Breakfast (B) at home
fast food
restaurant
Lunch (L)
at home
fast food
restaurant
Dinner (D)
at home
fast food
restaurant
Snacks (S)
at home
fast food
restaurant

Pls. specify fast food/restaurant: ____________________

(Continuation)

Dessert
Cake
Ice Cream
Fruit
Salad
Others, please specify ____________________

Where do you take your meals during weekends?

Breakfast (B) at home
fast food
restaurant
Lunch (L)
at home
fast food
restaurant
Dinner (D)
at home
fast food
restaurant
Snacks (S)
at home
fast food
restaurant

Pls. specify fast food/restaurant: ____________________

Beverage
Canned Juice
Coffee
Soda (regular or light)

How many meals do you usually have in one (1) day?

3 meals (B,L,D)
with 1 snack
2 meals, please specify ___ with 2 snacks
1 meal, please specify ____ with 3 snacks and up

Who prepares your meal?

Family member
Helper

Spouse
Yourself

Who buys your groceries?

Family member
Helper

Spouse
Yourself

Dining Out
When you are in a restaurant, what do you usually order?

Soup
Cream-based
Clear Soup

Vegetable
Sauted
Salad
Stir-fried

Main Course (Please rate according to preference (1

being the 1st preference and 5 being the least liked):
___ Beef
___ Fish
___ Seafood
___ Chicken
___ Pork
___ Others, please specify _______

Dessert
Cake
Ice Cream
Fruit
Salad
Others, please specify ____________________

Beverage
Canned Juice
Iced Tea
Tea
Coffee
Fresh Juice Water
Soda (regular or light)
If with sugar, is it
Table sugar Artificial
Others, please specify _________
At Home
What do you usually eat at home?

Soup
Cream-based
Clear Soup

Vegetable
Sauted
Salad
Stir-fried

Main Course (Please rate according to preference (1

being the 1st preference and 5 being the least liked):
____ Beef
____ Fish
____ Seafood

Iced Tea
Tea
Fresh Juice Water

If with sugar, is it
Table sugar Artificial
Others, please specify ____________________

Is there anyone living with you who follows a specific diet

program?
Yes
No
If yes, please specify who ________________
6.

How do you like your foods cooked?

Baked
Fried
Steamed
Stir-fried
Boiled
Grilled
Others, ________________

7.

Do you eat junk foods?

Yes No
If yes, what type? Chips
Chocolate
Others, __________________________

8.

Do you drink alcoholic beverages?

If yes, what type?
Beer
Liquor
If yes, how often?
____ times per day
____ times per week

Yes

No

Wine Others, _________

Occasional

If occasional, how many drinks?

1 drink
2 drinks more than 2 drinks
9.

Do you eat out often? Yes No

If yes, how many times in a week?
Once
2 times
4 times and above

3 times

REVIEWED AND CHECKED BY:

_______________________________________________________
Signature Over Printed Name/ Date & Time

____ Chicken
____ Pork
___ Others, please specify _______
MED-FRSF-NNM-006

NMS STAFF-IN-CHARGE

Rev1Iss2 02-Mar-2012