QUESTIONNAIRE

PURPOSE: TO STUDY ABOUT THE DAILY FOOD INTAKE OF THE

FAMILIES THAT THEY ARE TAKING BALANCED DIET OR
NOT.

BALANCED DIET: DIET PLAYS VITAL ROLE IN KEEPING AND

MAINTAINING A HEALTHY BODY. A DIET IS CALLED BALANCED
WHEN IT COMPRISES OF ALL THE BASIC NUTRIENTS THAT
BODY REQUIRES AND ALSO THE CALORIE REQUIREMENTS OF
AN INDIVIDUAL.

BALANCED DIET CHART FOR INDIANS

FOOD GROUP QUANTITY SOURCES

CEREALS 300 gm WHEAT,RICE,MILLETS
60gm (VEG)

PULSES 30gm (NON VEG) SPROUTS/FERMENTED

MEAT 30gm CHICKEN,FISH
VEGETABLES 300gm min. PEAS,CARROT,PUMPKINS,BEANS
,GREEN

LEAF VEGETABLE etc.

FRUITS 100gm ORANGE,APPLE,PAPAYA,,GUAVA
,

MANGO etc.
MILK & MILK 300gm CHEESE,CURD etc.
PRODUCTS
SUGAR 20gm CONFECTIONARY
FATS 20gm OIL/BUTTER/GHEE

DAILY CALORIE NEEDED FOR AN INDIAN FAMILY

 0-6 yrs 650-1800 cal/day

CHILDREN 6-12 yrs 1800-2700 cal/day

12-18 yrs 2700-3000 cal/day
MEN 18 yrs onwards 2700 cal/day
18 yrs onwards 2000 cal/day

WOMEN Expecting mother 2300 cal/day

Lactating mother 2400-2700 cal/day

QUESTIONS TO BE ASKED:

1. What is your name?

2. Age :___________
3. Sex : M F
4. Are you vegetarian? Yes No
5. How often do you take breakfast
Daily Sometimes None
6. Regular meals
3 or more 2 times daily not regular
7. Fruits and vegetables
5 or more full servings 2-4 servings per
day

1 or less don’t eat

8. Fats taken
Nuts,olive oils,fatty fish low fat
Very low carbohydrate diet Meats,milks or
cheese
Baked food,deep fried
9. Refined foods
No refined foods
Some refined foods
Bread,rice,cereals,packaged foods
Sugar,soft drinks,sweet,snack foods
10. Alcohol
None
1 drink daily
2 drinks daily
3-6 drinks daily
More than 6
11. Non alcoholic beverages taken
____________________________________
 HEALTH QUESTIONNAIRE
TABLE 1

FREQUENCY

FOOD TYPE/AMOUNT ALWAY USUALLY SOMETIM NEVER

S ES

3 OR MORE TIMES DAILY

REGULAR 2 TIMES DAILY

MEALS
NOT REGULAR

5 OR MORE FULL SERVINGS

DAILY
FRUITS
AND 2-4 SERVINGS DAILY
VEGETABL
1 OR LESS
ES
DON'T EAT

NUTS,OLIVE OILS,FATTY
FISH

LOW FAT CREAM

FATS
VERY LOW CARBOHYDRATE
DIET

MEATS,MILK OR CHEESE

BAKED FOOD,DEEP FRIED

NO REFINED FOODS

SOME REFINED FOODS

REFINED BREAD,RICE,CEREALS,PACK
FOODS AGED FOODS

SUGAR,SOFTDRINKS,SWEET
,SNACK FOODS

NONE

1-2 DRINKS

ALCOHOL 3-6 DRINKS

MORE THAN 6
 NON
ALCOHOLI
C
BEVERAGE
S