St.

Anthony’s College
NURSING DEPARTMENT
San Jose de Buenavista, 5700 Antique

Client No. 1
24 - HOUR RECALL
1. What time did you go to bed the night before last?
- 11 pm
Was this the usual time?
- YES
2. What time did you get up yesterday?
- 5 am
Was this the usual time?
- YES
3. When was the first time you had anything to eat or drink?
- OCTOBER 16, 2019 (7AM)

What did you have and how much?

- 3 pcs. bread and a cup of milk

4. When did you eat again?

- OCTOBER 16, 2019 (12PM)
Where?
Boarding House
What and how much?
- 1 cup of rice , Menudo and 1 glass of water
5. When did you eat and how much?
- 4 pm, bread and 1 glass of water
6. Did you eat or drink anything else?
a. Anything from 1st to 2nd meal?
- none
b. Anything from 2nd to 3rd meal?
- none
c. Anything from 3rd meal to bed time?
- 1 cup of milk
7. Was this day’s food intake different from usual?
- No
If so, why?
8. Is weekend eating different?
- Yes
If so, why?
- Because, different food served at home.
 St. Anthony’s College
NURSING DEPARTMENT
San Jose de Buenavista, 5700 Antique

Client No. 2
FOOD FREQUENCY QUESTIONNAIRE
1. Do you drink milk? If so, how much? What kind?
- Yes, 1 glass of milk - Whole
2. Do you use fat? If so, what kind?
- No
3. How many times do you eat meat? How many times do you eat egg?
- 3 time a day -Rarely
How many times do you eat cheese? How many times do you eat beans?
-Occasionally -Rarely
4. Do you eat snack foods? If so, which ones?
- Yes. Burger & Street Foods
 St. Anthony’s College
NURSING DEPARTMENT
San Jose de Buenavista, 5700 Antique

How often? How much?

-Depending on the availability of tine - Depending on what I want
5. What vegetables do you eat? (in each group) How often?
-Sweet Potato and Peas , Rarely
a. BROCCOLI, COOKED GREENS, SWEET POTATO, CARROTS
b. TOMATO, COOKED CABBAGE, CAULIFLOWER, PEAS, LETTUCE
6. What fruits do you eat and how often?
- Banana, Raisins and Orange, Rarely
a. APPLE, BANANA, CHERRIES, GRAPE, BERRIES, RAISINS, PEACHES
b. ORANGE, GRAPE FRUIT, ORANGE FRUIT JUICE, GRAPE FRUIT JUICE
7. Bread and cereal products
a. How much bread do you usually eat with each meal?
- 2x
How much bread do you usually eat between meal?
- 2x
b. Do you eat cereal? (daily, weekly)
- NO

c. How often do you eat foods such as macaroni, spaghetti, noodles, and the like?
- Occasionally
8. Do you use salt? Do you crave salt or salty foods?
- Yes - Sometimes
9. How many tsp of sugar do you use/ day?
- 1 1/2
10. Do you drink water? How often during the day?
- Yes -After eating and when I feel thirsty
How much each time? How much would you say you drink each day?
-1L a day - 5-6 glasses
 St. Anthony’s College
NURSING DEPARTMENT
San Jose de Buenavista, 5700 Antique

11. Do you drink alcohol? How often?

- No
How much? Beer, wine , others?
-

Client No. 3
DIETARY HISTORY
1. ECONOMICS
a. Income
- 20, 000 monthly
b. Amount of money for food each week or month and individual perception of its adequacy for meeting
food needs.
- 3000 weekly
2. Physical Activity
a. Occupation
- Student
b. Exercise
- Brisk-walking
 St. Anthony’s College
NURSING DEPARTMENT
San Jose de Buenavista, 5700 Antique

c. Sleep - hours/ day

- 6 to 8 hours daily
3. Ethnic and Cultural Background
a. Influence and eating habits
- Family
b. Religion
- IFI
c. Education
- College Student
4. Home Life and Meal Patterns
a. Number of household members
- 5 members
b. Person who does shopping
- Tita and me
c. Person who does cooking and relationship with this person
- Grandfather and me

d. Food storage and cooking facilities

- Refrigerator, Gas Stove and Charcoal
e. Type of housing
- Semi-concrete
f. Ability to shop and prepare food
- Can do shopping and prepare food properly
5. Appetite
a. Good
b. Factors that affect appetite
- Stress
c. Taste and smell perception
- Can taste and can smell properly
 St. Anthony’s College
NURSING DEPARTMENT
San Jose de Buenavista, 5700 Antique

6. Allergies, Intolerances and Food Avoidance

a. Foods avoided and reason
- Seafoods, Allergic
b. Length of time of avoidance
- None
7. Dental and Oral Health
a. Problems with eating
- None
b. Foods that cannot be eaten
- None
c. Problems with swallowing, salivation and food sticking
- None
8. Gastrointestinal Concern
a. Problems with heartburn, bloating, gas, diarrhea, constipation, distention
- Constipation (if less fluid intake)

b. Frequency of Problems
- 1 day
c. Home Remedies
- Liniment, Water
d. Antacid, laxative and other drug use
- None
9. Chronic diseases
a. Treatment
- None
b. Length of time of treatment
- None
c. Dietary modification
- None
 St. Anthony’s College
NURSING DEPARTMENT
San Jose de Buenavista, 5700 Antique

10. Medication
a. Vitamin and / or mineral supplement
- Vitamin D and C
b. Medications
- None

24 – Hour Recall, Food Frequency and Dietary History

PRESENTED TO:

LIANNA ROSE D. ESPINO, RN

Clinical Instructor

St. Anthony’s College

San Jose de Buenavista, Antique

 St. Anthony’s College
NURSING DEPARTMENT
San Jose de Buenavista, 5700 Antique

In Partial Fulfillment of the Requirements in

NCM 104 (NUTRITION AND DIET THERAPY)

First Semester S.Y. 2019-2020

By

Mary Joyce V. Ungsod

BSN 2B

October 17, 2019