Evaluation Sheet: I.PERSONAL INFORMATION Head of the Family: Name: __________________________________ Age: ____ Ht. (cm): _____ Wt.

(kg): ____ Religion: ________ Occupation: _____________ Educational Attainment: ____ Elementary Undergraduate ____ Elementary Graduate ____ High School Undergraduate ____ High School Graduate ____ College Undergraduate ____ College Graduate ____ Vocational Socio-Economic Status: ____ Below P5,000 ____ P5,000 P10,000 ____ P10,000 P15,000 ____ P15,000 P20,000 ____ P20,000 P25,000 ____ P25,000 P30,000 ____ Above P30,000 NAME AGE

Spouse Maiden Name: Name: __________________________________ Age: ____ Ht. (cm): _____ Wt. (kg): ____ Religion: ________ Occupation: _____________ Educational Attainment: ____ Elementary Undergraduate ____ Elementary Graduate ____ High School Undergraduate ____ High School Graduate ____ College Undergraduate ____ College Graduate ____ Vocational Socio-Economic Status: ____ Below P5,000 ____ P5,000 P10,000 ____ P10,000 P15,000 ____ P15,000 P20,000 ____ P20,000 P25,000 ____ P25,000 P30,000 ____ Above P30,000 CHILDREN SEX HT. WT. E.B OCCUPATION

II. HEALTH STATUS 1. Do you eat 3 times a day? If no how many times? __ Yes __ No, _____ 2. Do cook your own food? __ Yes __ No 3. Do you drink atleast 8 glasses of fluids a day? __ Yes __ No 4. Is there anyone who drinks alcoholic beverage in your family? If yes how many? __ Yes,___ __ No 5. Is the anyone who smoke in the family? If yes how many? __ Yes,___ __ No 6. Do you sleep atleast 8 hours a day? __ Yes __ No 7. Do you brush your teeth atleast 3 times a day? If no how many times? __ Yes __ No,____ 8. Do you take a bath everyday? __ Yes __ No 9. Do you exercise regularly? __ Yes __ No 10. Is there anyone who suffers from any illnesses in the family? If yes how many? (Pls. Specify) __ Yes,________________ __ No

III. FREQUENCY FOOD ANALYSIS NOTE: 5 Mostly Consumed 4 Sometimes Consumed 3 Consumed 2 Frequently Consumed 1 Never Consumed FOOD GROUPS A.Cereals & Products 1.Grains 2.Breads,Cookies,Biscuits,Crackers,Pastries 3.Noodles,Pasta 4.Native Snacks 5.Flavored puffs & Expanded Snacks B.Starchy Roots & Tubers 1.Roots and Tubers 2.Processed/Products C.Nuts,Dried Beans & Seeds 1.Dried Beans and Seeds 2.Processed/Products D.Vegetables and Products 1.Leafy green 2.Fruit vegetables & Flowers, Fresh Leguminous Vegetables 3.Fresh Seeds in Pods 4.Processed/Products E.Fruits & Products 1.Fresh,Dried,Canned Fruits 2.Fruit Juice Extract 3.Processed/Products F.Meat and Other Animals and Products 1.Meat and Poultry 2.Other Animals 3. Processed/Products G.Finfish,Shellfish and other aquatic animals and Products 1.Shellfish, Finfish and other aquatic animals 2.Processed/Products H.Eggs & Products 1.Eggs 2.Processed/Products I.Milk and Products 1.Milk 2.Cream 3.Milk-based Products J.Fats & Oils 1.Animals fats,Vegetable Oils 5 4 3 2 1

2.Foods w/ fat or oil as major component 3.Oil-based products K.Sugar, Syrup and Confectionary 1.Sugar and Syrup 2.Confectionary and sweets 3.Jam,Jellies, and preservatives L.Spices and Condiments 1.Salt,seasonings,sauces,vinegar M.Alcoholic Beverage 1.Beer and Other liquors 2.Wine 3.Distilled Liqours 4.Other Alcoholic Beverage