Nutrition Assessment, Monitoring and Surveillance
e20161124-Hour Recall Intake Questionnaire
Login Number:
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Date of Recall: |
Date of birth:
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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: ______
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Weight: |
Height: |
Physical Activity:
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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. |
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Time |
Am (1) Pm (2) |
Recipe |
Food |
Source:
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Amt. served for consumption |
Amt. left on plate |
Preparation |
Recipe description if not prepared by respondent: |
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Comments:
24-hour recall intake forms, Constance Gewa 2011