宁夏地区老年人膳食频率调查表

编号
    ____________
姓名
    ____________
性别
年龄
    ____________
民族
身高(cm)
    ____________
体重(kg)
    ____________
腰围(cm)
    ____________
总人数
    ____________
吸烟
饮酒
每月总经济收入?(元)
    ____________
每月采购食物花费?(元)
    ____________
病史
糖尿病
高血压
其他
膳食频率表
不吃 次/天 次/周 次/月 次/年 每次食用量 两/毫升
____________ ____________ ____________ ____________ ____________ ____________
____________ ____________ ____________ ____________ ____________ ____________
杂粮 ____________ ____________ ____________ ____________ ____________ ____________
薯类 ____________ ____________ ____________ ____________ ____________ ____________
豆制品 ____________ ____________ ____________ ____________ ____________ ____________
猪肉 ____________ ____________ ____________ ____________ ____________ ____________
禽兽 ____________ ____________ ____________ ____________ ____________ ____________
牛、羊 ____________ ____________ ____________ ____________ ____________ ____________
鱼虾类 ____________ ____________ ____________ ____________ ____________ ____________
新鲜蔬菜 ____________ ____________ ____________ ____________ ____________ ____________
新鲜水果 ____________ ____________ ____________ ____________ ____________ ____________
腌制品 ____________ ____________ ____________ ____________ ____________ ____________
____________ ____________ ____________ ____________ ____________ ____________
油炸 ____________ ____________ ____________ ____________ ____________ ____________
坚果 ____________ ____________ ____________ ____________ ____________ ____________
奶制品 ____________ ____________ ____________ ____________ ____________ ____________
饮料 ____________ ____________ ____________ ____________ ____________ ____________
酒类 ____________ ____________ ____________ ____________ ____________ ____________
食用油 ____________ ____________ ____________ ____________ ____________ ____________
备注说明:1两=50g
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