Mapping of Nutrition and Health status

24 Hours Diet Recall Survey Form

Are you filling for others

State

District

Pincode

Name

Gender

Mobile Number (Optional)

Date of Birth

Age

Choose Height Metric System:

Reported Height in cms:

Weight

Marital status

Educational status

Major occupation

(*** If you hadn't consumed any food at any meal pattern then select "Not consumed any food item" choice from the list and enter quanty as 0)

Meal Patterns

Foods consumed

Food Recipes	Food Quantity (grams/ml)
Select Food Recipe	Consumed food quantity

Food Recipes	Food Quantity (grams/ml)
Select Food Recipe	Consumed food quantity

Food Recipes	Food Quantity (grams/ml)
Select Food Recipe	Consumed food quantity

Food Recipes	Food Quantity (grams/ml)
Select Food Recipe	Consumed food quantity

Food Recipes	Food Quantity (grams/ml)
Select Food Recipe	Consumed food quantity

Food Recipes	Food Quantity (grams/ml)
Select Food Recipe	Consumed food quantity

Food Recipes	Food Quantity (grams/ml)
Select Food Recipe	Consumed food quantity

Food Recipes	Food Quantity (grams/ml)
Select Food Recipe	Consumed food quantity

(***For above 18 years people only)

Chronic Problem	Under Treatment	Chronic Problem	Under Treatment
Hypertension	Yes No	Kidney Diseases	Yes No
DiabetesMellitus	Yes No	Heart attack	Yes No
Stroke	Yes No	Cancer	Yes No
Asthma	Yes No	Chronic obstructive pulmonary disease(COPD)	Yes No
Hypothyroidism	Yes No	Dementia	Yes No
Gastritis	Yes No	Polycystic ovarian syndrome (PCOS)	Yes No
Mention other's if Any	Yes No