Form by: Kikete Joseph Wanjala

Pearson NCS MM64979-1

Dear Respondent,
The researchers are from Grade 12 ABM-A students in Mariveles National High School-
Camaya Campus. The purpose of this study is to determine the impact of nutritional status to the
academic performance of 12 ABM-A. Answering questions will only take 15 minutes of your time.
Also, the researchers promise that your personal information and responses will be treated with
confidentiality. Your participation in the study is voluntary, you do not have to answer questions
that makes you uncomfortable. Thank you for your time.
Shella Marie Palad
John Marlou Gaspar
Dames Elisse Sabellano
I. DEMOGRAPHIC INFORMATION
Name of respondent (optional):
Sex: Age:

II. BODY MASS INDEX (BMI)

BMI= Weight (kg)/Height (m2)

Weight1 Weight2 Average Height1 Height2 Average BMI

(kg) (kg) Weight (meters) (meters) Height

Please check (/) the most appropriate response.

III. INTAKE OF BREAKFAST
iii.i Do you take breakfast in the morning before coming to school?
Yes No Not always
iii.ii If yes, what do you take?
Rice. Vegetables. Bread Meat, eggs, fish, milk. Fruits.
iii.iii If not always, what do you take?
Rice. Vegetables. Bread Meat, eggs, fish, milk Fruits.
Please respond to the following by placing a check (/) mark in the Yes or No column.
IV. EATING HABITS

Question Food Examples Yes (1) No (0)

Number Group
1. Cereals Bread, noodles, biscuits, cookies, and
others
2. Vitamin A Carrots, squash, or sweet potatoes, leafy
rich vegetables. Fruits like ripe mangoes,
vegetables papayas, and others.
And fruits
3. Organ Liver, kidney, heart, or blood-based foods
meat
4. Flesh Beef, pork, goat, chicken, duck, or other
meats birds
5. Eggs
6. Fish Fresh or dried fish or shell fish
7. Nuts & Beans, peas, nuts, seeds, and others
Seed
8. Milk Milk, cheese, yogurt, or other milk
products products
9 Oils and Oil, fats, or butter added to food or used
fats for cooking
10. Sweets Sugar, honey, soda, chocolate, candies
11. Coffee/ Tea (black, green, herbal) or coffee
Tea
SCORE:

Kindly tick (|) the most appropriate response

V. PERFORMANCE OUTCOME
vi.i What is your last school year’s academic performance (final average)
79 and below. 80-84. 85-90 91-95. 96 and above
VI. ATTENDANCE
vi.i Do you excused in the class for personal reasons (like health reasons?)
Yes. No
vi.ii Do you miss class in the school?
Always. Sometimes. Never
VII. PARTICIPATION
vii.i Do you participate in a group or class discussion in your school?
Always. Sometimes. Often. Never
Please indicate your response to the following statements by circling the number which more
correspose to your evaluation
VIII. SOCIO-ECONOMIC STATUS

 wall
A. Mud. B. Blocks. C. Wood. D. Others (specify)

 floor
A. Mud. B. Cemented. C. Others (specify)

 What are the two main sources of energy you use for cooking?
A. Wood. B. Charcoal. C. Gas D. Electricity. E. Others
IX. PERSONALITY

 Is your eating habits make you a healthy person?

A. Yes. B. No. C. I don’t think so
X. HYGIENE AND SANITATION

 What are the two main sources of water that you use at home?
A. Dam. B. Piped water. C. Wells. D. Others
 Do you treat your drinking water?
A. Yes. B. No
 If yes, which of the following methods do you use?
A. Boiling. B. Chlorination. C. Others
 Do you have toilet at home?
A. Yes. B. No
 If no, where do you go?
A. Open field. B. Behind the house C. Others

 At what times do you wash your hands? (multiple answers are possible)

A. After visiting the toilet. D. When I think that they are dirty
B. Before eating. E. When water is available
C. Before preparing food F. Other (specify

Thank you for taking the time to complete this questionnaire