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Questionnaire Number: ______

BACKGROUNDINFORMATION

1 (Son/Daughter) 2 (Mother) 3 (Father)

Name

(Surname, Given Name, MI)

Gender

Birthdate

(Month, Day, Year)

Age

(Years)

Year/Course

(if studying)

Occupation

(if working)

Present City/Town

of Residence

Present Province

of Residence

Years Living

in Present Residence

* Present residence refers to house where one stays more than 50% of the time during a typical week.

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Anthropometric

Measures:1 2 3

Weight (Kg)

Height (m)

Bideltoid (cm)Biacromial (cm)

Shoulder (cm)

Chest (cm)

Waist (cm)

High Hip (cm)

Hip (cm)

Triceps skin fold

Upper Arm Length

Upper Arm Circumference

Lower Arm Length

Lower Arm Circumference

Elbow Breadth

Upper Leg Length

Upper Leg Circumference

Lower Leg Length

Lower Leg Circumference

Kneecap width

Identify Body Type: 1 2 3

Endomorph

thin, linear appearance

narrow waists, hips, and shoulders

tend to have low levels of body fat

have a hard time gaining leanmuscle mass

lose weight easily

Mesomorph

have an athletic build

broad shoulders & a narrow waist

have a fast metabolism

gain muscle mass easily

Ectomorph

have big bones

round faces with large thighs & hips

high waist

stocky appearance

Weight loss is most difficult

high levels of body fat

small hands and feet

have arms and legs that tend to beshort and tapering

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Identify Body Shape: 1 2 3

HourGlass

Narrow waistline

Large bust and broad hips

Bust and hips almost same

Bust & hips differ around 1inch only

Waist is 25cm less than hips

Waist is 25cm less than bust

Figure envied by females

Tend to gain weight all over body

Easily increases chest size

Easily increases hips

Waist smaller than hips

Identify Body Shape: 1 2 3

Triangle

Pear/Spoon/Bell Shape Body

Fuller bottom and legs

Broad hip/buttocks

hips slightly wider than shoulders

tend to gain weight below waist

small chests and flat stomachs

larger lower bodies and smallerupper bodies

Trapezoid Shaped Body

tent to gain weight along thebackside

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Identify Body Shape: 1 2 3

Oblong

Apple/Rounded Shape Body

Big belly or abdomen

Wide waist

Stomach wider compared to hip

Arms and legs short

slim hips & a large chest & stomach

tend to gain weight above the waist

bigger on the top half of their bodiesthan on the bottom half

Inverted Trapezoid Body

Identify Body Shape: 1 2 3

InvertedTraingle

V Shaped body

Tulip Shaped Body

Broad shoulders

Flat bottom and slim legs

Muscular

Large bones

Thigh and hips smaller than bust andshoulder

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Identify Body Shape: 1 2 3

SlimRectangel

Pencil Shaped Body

Columnar Shaped Body

Slim figure

Long legs

maintain slender arms and legs

put on weight in their stomach andbackside

Same shoulder and hips

Waist near value of hips and bust

no large difference in size of theirhips, waists, and shoulders

Identify Body Shape: 1 2 3

WideRectangle

Stocky

Big built

Boyish Shape

Tendency to gain weight

Large arms and legs

Identify Body Frame/Built 1 2 3

Large/Big (Bones)

Medium (Bones)

Small (Bones)

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Lifestyle 1 2 3

Inyouropinion,

whatisyour

Levelof

Activity:

Active

Semi-active

Moderate

Semi-sedentary

Sedentary (little or no physical activity)

How

wouldyoucharacterizey

our

dietintermsoffatintake?

Low (Nearly all the time)

Low (Most of the time)

Moderate (Most of the time)

High (Most of the time)

High (Nearly all the time)

How

wouldyoucharacterizeyour

dietintermsofPROTEINi

ntake

?

Low (Nearly all the time)

Low (Most of the time)

Moderate (Most of the time)

High (Most of the time)

High (Nearly all the time)

Lifestyle 1 2 3

How

wouldyoucharacte

rizeyour

dietintermsofCARBOH

YDRATE

intake?

Low (Nearly all the time)

Low (Most of the time)

Moderate (Most of the time)

High (Most of the time)

High (Nearly all the time)

How

wouldyoucharacterizeyour

dietintermsofFIBERintake?

Low (Nearly all the time)

Low (Most of the time)

Moderate (Most of the time)

High (Most of the time)

High (Nearly all the time)

How

wouldyoucharacterizeyour

dietintermsofSUGARinta

ke?

Low (Nearly all the time)

Low (Most of the time)

Moderate (Most of the time)

High (Most of the time)

High (Nearly all the time)

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Lifestyle 1 2 3

How

wouldyoucharact

erizeyour

dietintermsofSALTintake?

Low (Nearly all the time)

Low (Most of the time)

Moderate (Most of the time)

High (Most of the time)

High (Nearly all the time)