7/28/2019 Diet - Copy.docx

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Name(First, M.I. Last):  M F  Faculty: 

Semester:  Weight:  Height: 

City/Punjab: Date of Birth: Age:

 ALL QUESTIONS CONTAIN IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL

Diet  Are you diet conscious? Yes No

 Are you dieting? Yes NoIf you are dieting, are you on a physician prescribed medical diet? Yes No

What are your weight goals? At what level of obese you think of yourself? Thin Healthy Pre-obese ObeseHave you been gaining or losing weight lately? Yes No Were you heavy as a child? Yes No

 Are you satisfied with your weight? Yes No Are you willing to make change in your diet? Yes  NoIn what way can losing weight change your life? Increase in confidence More energetic Be Healthy  It won’t effect  No ideaWhat difficulties do you have dieting? Eating habits Society factor No difficulties No proper diet plan Satisfied with your diet planDo you eat when you are emotionally sad, angry, bored etc…?  Yes NoWhat time do you have lunch? 12 pm 1 pm 2 pm 3 pm 4 pmWhat time do you have dinner? 7 pm 8 pm 9 pm 10 pm 11 pm or lateNumber of meals you eat in an average day? 1 2 3 4 5 or more

Rank salt you intake daily? none low med high very highRank fat/oil you intake daily? none low med high very highRank sugar you intake daily? none low med high very highRank water you intake daily? none low med high very highRank junk food you intake daily? none low med high very highNumber of cups of tea you intake daily? 1 2 3 4 5 or moreNumber of cups of coffee you intake daily? 1 2 3 4 5 or moreNumber of cans/bottle of cold drinks you intake daily? 1 2 3 4 5 or moreHow much calories you intake in a day? no idea low

(1000cal) med(2000cal)

high(3500cal)

very high(4500cal)

How much calories you burn in a day? no idea low(500cal)

med(2000cal)

high(3500cal)

very high(4500cal+)

Do you smoke? Yes NoDo you have trouble sleeping? Yes NoDo you have any disease? Yes No

Exercise Sedentary (No exercise)

Mild exercise (i.e., climb stairs, walk 3 blocks, golf) Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)

What do you normally eat for the following meal?

Breakfast? Milk products Bread and egg Desi Breakfast (e.g. Pharata) NothingLunch? Home-made Market food Fast food (e.g. Burger, pizza) NothingDinner? Home-made Market food Fast food (e.g. Burger, pizza) Nothing

Drink you intake after any meal Pepsi Coca Cola Sprite /Dew Fanta /Marinda Tea Coffee Just Water Any Other Nothing

What is your favorite food for…? 

Breakfast? Milk products Bread and egg Desi Breakfast (e.g. Pharata) NothingLunch? Home-made Market food Fast food (e.g. Burger, pizza) NothingDinner? Home-made Market food Fast food (e.g. Burger, pizza) NothingDrink you intake after any meal? Pepsi Coca Cola Sprite /Dew Fanta /Marinda Tea Coffee Just Water Any Other Nothing

Which type of food you most prefer?

Red Meat (Mutton/Beef) White Meat (Chicken, Fish) Vegetables, beans Anything

DIET CONSCIOUSNESS AMONG YOUNGSTER 

 All questions contained in this questionnaire are strictly confidential and will become part of your medical record.