Nutrition Assessment, Monitoring and Surveillance

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Twenty_fourhourrecallIntakeforms1.doc

24-Hour Recall Intake Questionnaire

Login Number:

Date of Recall:

Date of birth:

Gender:

Pregnant  Yes  No

If Yes, months pregnant: __________

Nursing/Breastfeeding  Yes  No

If Yes, months postpartum: __________

6. Dietary Supplement use in last 6 months  Yes  No

If Yes, supplement name: __________

Amount consumed / day: ______

Weight:

Height:

Physical Activity:

Comments:

Intake form

Key: Recipe: (Mixed dish=1, Single food=2)

Source: (Own home=1, Outside home=2)

Preparation (Prep): (Raw=1, Boiled=2, Fried=3, Roasted=4, Baked=5, Other=6 (specify)

I would like to know about the foods that you ate from the time you woke up to the time you went to bed yesterday.

Time

Am (1)

Pm (2)

Recipe

Food

Source:

Amt. served for consumption

Amt. left on plate

Preparation

Recipe description if not prepared by respondent:

Comments:

24-hour recall intake forms, Constance Gewa 2011