CHESTIONAR ALIMENTAR I DE EVALUARE A STILULUI DE VIA

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Vrs!: _________________________________________________________________________
Se": ____________________________________________________________________________
Me#iu #e $r%&enien'!: ____________________________________________________________
O(u$)'ie: _______________________________________________________________________
*reu)e: _______________________________________________________________________
+n!,'ime: ________________________________________________________________________
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Di)-n%si( (,ini(: _________________________________________________________________
Nr. /iei #e %0ser&)'ie: ____________________________________________________________

A,er-ii: _________________________________________________________________________
Ai su1eri iner&enii (2irur-i(),e3
a. Da
b. Nu
C)n# )i su1eri iner&eni) (2irur-i(),)3
Ai urm) r))men (u r)#i%er)$ie s)u (2imi%er)$ie3
a. Da
b. Nu
D)() DA (e r))men si $e (e $eri%)#)3
Cum &4)i simi #u$) )(es r))men3 Des(riere m)ni1es)ri (,ini(e:
Sune'i 1um!%r3 :
a.Fost fumtor
b.Nu
c.Da

Ce 'i-!ri )'i 1um)51um)'i $e 6i3
a.ntre 1 i 10 igri pe zi
b.ntre 10 i 20 igri pe zi
c.Peste 20 de igri pe zi
De ('i )ni sune'i5)'i 1%s 1um!%r3
a.Mai puin de ani
b.ntre i 10 ani
c.ntre 10 i 20 ani
d.Mai mu!t de 20 ani
7i1)'i #)(! #umne)&%)sr! s)u mem0rii 1)mi,iei #umne)&%)sr! )u 8n is%ri( un) #in
urm)%)re,e )1e('iuni:
"oa! #u Fami!ie "oa! #u Fami!ie
$nemie "o!i de rinic%i
&ancer 'bezitate
Diabet "o!i de inim
(ipertensiune $feciuni a!e tiroidei
(iperco!estero!emie $pnee de somn
$feciuni digesti)e*u!cer
gastric+duodena!,
$!te!e-
Ai s,)0i in u,imu, )n3
a.Da.cat/
b. Nu

A'i in(er() s! s,)0i'i 8n re(u3
a.Nu
b.Da
Cum3
a.0egim a!imentar
b.1port
c.$!te!e- 2222222222222222222222222222222222222222222222222222222222222222222222222
Sune'i su$us sresu,ui3
a.Nu
b.Da
Ce i$ #e )(i&i!'i 1i6i(e $r)(i()'i3
A(i&i!'i us%)re Ore56i
Mers pe 3os
Munc de birou
Mers pe bicic!et usor
$spirat co)oare
#4erciii de intindere
56mp!rie
Munc in gara3
$!te!e-
A(i&i!'i m%#er)e
Mers pe 3os rapid
5uns iarba cu maina e!ectric
Mers pe bicic!et 7n ritm a!ert
1p!are geamuri
Frecat pode!e
0idicat greutai
$cti)iti agrico!e
$!te!e-
A(i&i!'i inense
8ogging+a!ergat
not
5uns iarba cu ec%ipament
nee!ectric
Mers pe bicic!et 7n panta+rapid
Mutat mobi!e
1pturi manua!e
$!te!e-
Ore #e %#i2n! 2222222222ore+zi2222222222zi!e +sptm6n
C #e #es (%nsum)'i 1ru(e3 $%r'ii56i
niciodat 1 2 9 : ;
<rapefruit+portoca!e+!m6i+pome!o+mandarine+c!ementine+
=i>i
Mere+ )iine+ciree timpurii+ caise+ piersici+cpuni
&iree t6rzii+ pere+ prune+ struguri
Pepene ga!ben+rou+ banane
Fructe de pdure
Fructe o!eaginoase *nuci + a!une + migda!e + fistic..,
$!te!e-
O $%r'ie ? @ grefA o fe!ie medie pepeneA
? @ can ciree+)iine+afine
? un mr+portoca!+piersic de dimensiune medie
? o banan medieA un ciorc%ine mediu de strugure
? un pumn nuci + a!une + migda!e + fistic
Ce 1e, #e ,e-ume (%nsum)'i 3 $%r'ii56i
niciodat 1 2 9 : ;
1a!at )erde+ spanac+ urzici
0oii+ ardei+ gogoari+ ceap )erde+ )inete+ psti+
ciuperci
Faso!e+ !inte+ mazre+ porumb boabe
Barz+ broco!i+ conopid+ castra)eti+ ridic%i
&artofi . fieri
. !a cuptor
. pr3ii
&eap+usturoi+ morco)+pstarnac+e!ina+ sfec!+ %rean+
praz+ sfec! rosie
1oia
$!te!e-
O $%r'ie ? o can !egume frunze crude
? o roie+castra)ete+ardei de dimensiune medie
? un cartof mediu sau @ can piure
? @ can faso!e+mazre+porumb boabe+rdcinoase fierte
Cum (%nsum)'i 1ru(e,e i ,e-ume,e 3 $%r'ii56i
niciodat 1 2 9 : ; C
Proaspete
&ompot
1uc
&onser)
Murturi
Piure
1ote
Da grtar
<em
Du!cea
$!te!e-
O $%r'ie 9 1 can compotA 2 !g gemA @ can piureA 1 pa%ar suc
C #e #es (%nsum)'i 1!in%)se 3 $%r'ii5s!$!mn!
niciodat 1 2 9 : ; C
<ri
'rez
Paste
Mm!ig
$!te!e-
O $%r'ie ? @ can grau+gri+orez+paste fierteA @ can mm!ig
C! $ine (%nsum)'i 3 1e,ii56i
niciodat 1.9 :.; C.E 10.1 1.20 F 20
$!b
Neagr
<ra%am
Gntermediar
1ecar
$!te!e -
O 1e,ie ? 20g
Pr%s$eime) $inii : 222222222222222222222222222222222222222222222222222222
Ce %u! (%nsum)'i 3 %u!5s!$!mn!
niciodat 1 2 9 : ; C
Fierte
Pr3ite
'c%iuri rom6neti
'm!et dietetic
n preparate
$!te!e -
C #e #es (%nsum)'i ,)()e 3 $%r'ii5s!$!mn!
niciodat 1 2 9 : ; C
Dapte du!ce
Dapte btut
Gaurt
"r6nz )aci+ca+urd
&aca)a!
5e!emea
"r6nz topit
1m6nt6n
"r6nzeturi dietetice din comer %iposodate
$!te!e -
O $%r'ie ? o can *200 m!, !apte+iaurt ? @ can br6nz de )aci
? 0 g te!emea ? o !ingur sm6nt6n
Ce 1e, #e ,)()e (%nsum)'i 3
Degresate *dietetice,
1emidegresate
Gntegra!e
Direct de !a rani
C #e #es (%nsum)'i ()rne 3 $%r'ii5s!$!mn!
niciodat 1 2 9 : ; C
Pasre pui+curcan
Porc s!ab+gras
Bit s!ab+gras
Pete gras+s!ab+oceanic
'rgane
1a!amA parizerA cren)uti
&6rnaiA mici
1unc presatA pastramA muc%i fi!e
&reier
&onser)e de carne+pete
$!te!e -
O $%r'ie ? 100 g carne gtit ? 200 g pete gtit? 100 g preparate
Cum (%nsum)'i ()rne) 3
niciodat rar frec)ent
Fiart
Pr3it 7n u!ei
Pr3it 7n untur+unt
<rtar
Da cuptor
5ocat perisoare+p6r3oa!e
&onser)
Frigrui
$!te!e-
Ce 1e, #e -r!simi (%nsum)'i3 $%r'ii5s!$!mn!
niciodat 1 2 9 : ; C
H!ei de ms!ine
H!ei de f!oarea soare!ui crud+pr3it
Hntur
Hnt
Margarin
Maionez
1m6ntn
$!te!e -
O $%r'ie ? o !inguri
C #e #es (%nsum)'i #u,(iuri3 $%r'ii5s!$!mn!
niciodat 1 2 9 : ; C
Du!ceaA gem
Miere de a!bine
Produse de patiserie du!ci *biscuiiA napo!itane,
&ioco!at
ng%eat
Foieta3e du!ci
$!te!e-
O $%r'ie ? o !inguri du!cea+miere ? 0 g cioco!at+7ng%eat ? un biscuit
Ce 1e, #e #u,(iuri (%nsum)'i3
niciodat rar frec)ent
&u za%r
&u 7ndu!citori
$!te!e-
C #e #es (%nsum)'i : $e s!$!mn!
niciodat 1 2 9 : ; C
1nac=s.uriA c%ips.uri
Popcorn
&o)rigi
(ot dog
Pizza
1%a>orma
1a!euriA biscuii srai
1and>is%.uri
$!te!e-
C #e #es 1%,%si'i :
&antitate apro4.+zi
1are . !a gtit
. 7n timpu! mesei
BegetaA de!i=at
Ptrun3e!A mrarA cimbruA
rozmarin etc. *condimente
aromatice,
"oia de ardei iuteA ardei iuteA
mutarA usturoiA %rean
$!te!e-
7!uuri: $%r'ii5s!$!mn!
niciodat 1 2 9 : ; C
1uc de fructe
1uc de !egume
1uc din comer . norma!
. !ig%t
$p . minera!
. p!at
. sifon
. de !a robinet
$!coo! . bere
. )in
. trie
$!te!e-
O $%r'ie ? I can suc de fructe sau !egume ? o can *20 m!, suc din comer sau ap
? 00 m! bere ? 10 m! )in ? 0 m! trie
C%nsum)'i ()1e) 3 $%r'ii56i
niciodat 1 2 9 : ; C
Norma!A natura!
Decofeinizat
Ness
O $%r'ie ? 100 m!
Cu (e 8n#u,(ii ()1e)u)3
a.Nu o 7ndu!cesc
b.&u !apte
c.&u za%r
d.&u 7ndu!citor
e.$!te!e- 2222222222222222222222222222222222222222222222222222222222222222222222222
4Nr. mese56i: ____________________________________________________________________
4 Mn()'i #imine)')3
a.Nu
b.Da