Nutrition Intake Form

The Nutrition Intake Form is a simple way for you to keep track of what you eat and drink each day. This form can be used to help you make healthier choices, and to monitor your progress over time.

Time to complete

3 minutes

Eligibility

Children under the age of five years, people who are pregnant and lactating, people with tuberculosis, and people suffering from acute malnutrition are eligible to fill the nutrition intake form.

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Questions for Nutrition Intake Form

1.

What is your name?

The answer should be a text input.
2.

Age

The answer should be a single choice:
  1. Under 18
  2. 18-24 years old
  3. 25-34 years old
  4. 35-44 years old
  5. 45-54 years old
  6. Over 55
3.

Gender

The answer should be a single choice:
  1. Male
  2. Female
  3. Other
  4. Prefer not to say
4.

Phone Number

The answer should be a phone number.
5.

Nationality

The answer should be a country.
6.

What is your weight?

The answer should be a text input.
7.

What is your height?

The answer should be a text input.
8.

How many meals do you eat per day?

The answer should be a text input.
9.

What types of food do you typically eat for each meal?

The answer should be a text input.
10.

Do you eat any snacks during the day?

The answer should be a text input.
11.

Do you drink any beverages other than water?

The answer should be a text input.
12.

What is your overall intake of calories per day?

The answer should be a text input.
13.

What is your overall intake of protein per day?

The answer should be a text input.
14.

What is your overall intake of fat per day?

The answer should be a text input.
15.

What is your daily water intake in ounces?

The answer should be a text input.
16.

Do you have any allergies?

The answer should be a text input.
17.

Do you have any medical conditions?

The answer should be a text input.

Similar Ideas

  • Daily Nutrition Intake Form
  • Child Nutrition Intake Form
  • Adult Nutrition Intake Form
  • Pregnancy Nutrition Intake Form

Here are some FAQs and additional information
on
Nutrition Intake Form

What is the purpose of the Nutrition Intake Form?

The purpose of the Nutrition Intake Form is to provide information about an individual's dietary intake and to identify any potential nutritional deficiencies.

Who should complete the Nutrition Intake Form?

The Nutrition Intake Form should be completed by anyone who is interested in receiving information about their dietary intake and identifying any potential nutritional deficiencies.

How much nutrition is needed daily?

According to research, women are likely to need between 1,600 and 2,400 calories a day, and men from 2,000 to 3,000. However, this depends on their age, size, height, lifestyle, overall health, and activity level.

Why is nutrient intake important?

A healthy diet throughout life promotes healthy pregnancy outcomes, supports normal growth, development, and aging, helps to maintain healthy body weight, and reduces the risk of chronic disease leading to overall health and well-being.

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