INFORMATII GENERALE DATA>

NUME _______Irimuş____________________ PRENUME ____Ioana_________________

TELEFON_____________0745534220_______ EMAIL ______________________________
OCUPATIE_Coafeză__ _________________ SEX_____f__ VARSTA ___23____ STATUT SOCIAL ____
necăsătorită______________ COPII ___0____

INFORMATII MEDICALE

GRUPA SANGVINA _____ CONDITII SPECIALE (Alaptare / Sarcina etc. ) ____Rh

Negativ____________Părinţi- B3 şi 01______________________

MEDICAMENTE ADMINISTRATE (prezent sau ultimele 6 luni): ( anticonceptionale, antibiotice, colesterol,

HTA etc.) _______________________S-au administrat medicamente pentru
răceli.________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________

SUPLIMENTE ALIMENTARE (vitamine, minerale, aminoacizi, pastile slabit, laxative, etc.)

:_______________________
________________________Nu__________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
___________________________________

STORIC MEDICAL:

PERSONAL FAMILIE
BOALA / SIMPTOM DESCRIERE / OBSERVATII
(varsta) (varsta)
ALERGII NU
ANEMIE NU
ANXIETATE /ATACURI PANICA NU
ASTM NU
BOLI AUTOIMUNE NU
CANCER NU NU
OBOSEALA CRONICA NU NU
DEPRESIE NU NU
DIABET NU DA-MAMA
BOLI PIELE NU ALERGII
INTOLERANTE / ALERGII ALIMENTARE LA ZAHĂR
BOLI FIERE DA-
BUNICA
GUTA NU NU
BOLI CARDIOVASCULARE NU NU
HEPATITA NU NU
BOLI INIMA NU NU
DISLIPIDEMII NU DA.MAMA
HIPERTENSIUNE ARTERIALA NU DA-MAMA
HIPOTENSIUNE ARTERIALA DA NU
HIPER / HIPO GLICEMIE NU DA-MAMA
BOLI DIGESTIVE NU NU
BOLI RINICHI NU DA-MAMA
BOLI PLAMANI NU NU
BOLI FICAT NU NU
OSTEOPOROZA NU NU
SINDROM PM NU NU
OVARE POLICHISTICE NU NU
PROSTATA NU NU
TIROIDA NU NU
BOLI DIGESTIVE NU NU
ALTELE NU NU

EVALUARE NIVEL ACTIVITATE FIZICA

ESTI O PERSOANA ACTIVA D.P.D.V. FIZIC? ________DA____

DACA NU, CE TE IMPIEDICA?

________________________________________________________________________
_____________________________________________________________________________________
___________

DACA DA, DETALIAZA:

TIP / INTENSITATE NR. ZILE / DURATA

ACTIVITATE ( scazuta – moderata – SAPTAMANA (ore)
ridicata)
YOGA / STRETCHING
CARDIO / AEROBIC Kangoo 3 1,2 ore
(alergat,bicicleta,inot,kangoo etc.)
ANTRENAMENT REZISTENTA (antrenament cu
greutati, pilates, clase tonifiere)
SPORTURI RECREERE
ALTELE

EVALUARE CORPORALA

INALTIME ____156____(cm) GREUTATE ___56,5_____ (kg) IMC ________ ( ideal 19-25 )

CIRCUMFERINTA TALIE ___72cm___ (risc crescut: femei > 88cm, barbati >102 cm)

CIRCUMFERINTA SOLD ____92___

Crestere / scadere in greutate in ultimul an? ____12kg_DA ______NU

DACA DA, CAT? ___12kg___ MOTIV _________________dieta +

kangoo_____________________________________________________
_____________________________________________________________________________________
___________

NECESAR ENERGETIC ACTUAL:

RMB: __________ Total kcal

RMB + Nivel activitate: _______________ Total kcal

OBIECTIV GREUTATE ___51____ TIMP ESTIMAT PENTRU ATINGEREA OBIECTIVULUI ______3 Luni_______

DESCRIE CE PRESUPUNE FIZIC ACEST OBIECTIV PENTRU TINE (cum te vezi la momentul atingerii
obiectivului)
______________________________.______________________________________________________
_____________________________________________________________________________________
___________________

CE ANUMTE TE MOTIVEAZA / IMPINGE SPRE ACEST OBIECTIV

______________________________Pentru sănătate.____________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________

CARE CONSIDERI CA AR PUTEA FI CELE MAI MARI PROVOCARI / PIEDICI ALE TALE IN ATINGEREA
OBIECTIVULUI (familie, program, bani etc.)________________________________Nu există
________________________________________ __________________________________________
_____________________________________________________________________________________
_________________________________________________________________
NECESAR ENERGETIC PENTRU ATINGEREA OBIECTIVULUI:

____1400______ Total kcal

__________ Proteine (% kcal) ______ Proteine ( g ) __________ Proteine (g/kg)

__________ Carbohidrati (% kcal) ______ Carbo ( g ) __________ Carbo (g/kg)

__________ Grasimi (% kcal) ______ Grasimi ( g ) __________ Grasimi (g/kg)

__________ Fibre (g)

ALTE MENTIUNI:
__________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________

STIL DE VIATA ALIMENTAR

ISTORIC DIETE:

IN PREZENT TII O DIETA / UN REGIM ANUME SAU AI TINUT IN TRECUT? __da____DA ______ NU

DACA DA, DETALIAZA:

DIETA VARSTA DESCRIERE

___ampla________________________22___________________________hipocalorică______________
______________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________

CE REZULTATE / CONSECINTE AU AVUT? ________________________________-12 KG.Stagnare în luna

decembrie.__________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________
AI MAI APELAT LA UN SPECIALIST IN NUTRITIE IN TRECUT? ______DA __nu____ NU

DACA DA, CE AI APRECIAT SI CE TI-A DISPLACUT LA EXPERIENTA RESPECTIVA?

AM
APRECIAT:____________________________________________________________________________
_____________________________________________________________________________________
____ MI-A DISPLACUT:
__________________________________________________________________________
_____________________________________________________________________________________
___

STIL DE VIATA ALIMENTAR:

CINE GATESTE CEL MAI MULT IN CASA?

_________________________________mama________________________

CU CINE IEI MASA DE OBICEI? _________________________cu

mama________________________________________

CE PREFERINTE ALIMENTARE AU ACESTE PERSOANE?

____________________________________________
_____________________________________________________________________________________
_____

CUM PREPARI DE OBICEI ALIMENTELE? (prajite, la cuptor, la abur, fierte etc.)_____la cuptor,
prăjite__________ ___________

CARE E METODA PREFERATA DE GATIT? DE CE? ___________ _________________________la

cuptor______________
_____________________________________________________________________________________
_____

CINE FACE CUMPARATURILE CEL MAI DES? DE UNDE? ______Ioana şi mama_____________

__________________________

CITESTI ETICHETELE ALIMENTELOR? _______DA ______ __

DACA DA, CE INFORMATII CITESTI?

_____________________________________________________________
_____________________________________________________________________________________
_____

DE CATE ORI PE SAPTAMANA MANANCI LA RESTAURANT? __________o dată__________

_____________________
DE CATE ORI PE SAPTAMANA MANANCI LA FAST-FOOD?
_________________________________nu_________

NUMERI CALORIILE PE CARE LE CONSUMI? ______ _______ NU

DACA DA, DE CE?

___________________________________________________________________________

EXISTA ANUMITE ALIMENTE PE CARE LE EVITI? ______ DA ______ NU

DACA DA, DETALIAZA MAI JOS:

ALIMENT _______________BROCOLLI_______________ MOTIV

___________________________________________

ALIMENT _______________________________ MOTIV

___________________________________________

ALIMENT _______________________________ MOTIV

___________________________________________

ALIMENT _______________________________ MOTIV

___________________________________________

ALIMENT _______________________________ MOTIV

___________________________________________

AI INTOLERANTE SAU ALERGII ALIMENTARE ? ______ ______ NU

DACA DA, DETALIAZA:

_______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________

ALIMENTE LA CARE POFTESTI _____________Cartofi prăjiţi, mămăligă, ciocolată, ciorbe cu

smântână____________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________
ALIMENTE CARE NU ITI PLAC __________________________________brocolli, carnea de
vită_______________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________

FUMEZI? ______ DA ______

DACA DA, CAT? ________________maxim 5 ţigări pe

zi_____________________________________________________________

CONSUMI ALCOOL? __________ NU

DACA DA, CAT DE DES

______________ocazional_________________________________________________, CE FEL DE
ALCOOL ___________________bere cu
lămâie_____________________________________________________________ SI IN CE CANTITATI
_________________________________o bere pe
săptămână________________________________________?

CAT DE DES CONSUMI URMATOARELE ALIMENTE:

2-3 4-5 1
2-3 ori / 1 data / 2-3
TIP ALIMENTE NICIODATA ori / ori / data /
luna sapt ori / zi
sapt sapt zi
FAST FOOD 0
MANCARE RESTAURANT da
SEMI-PREPARATE da
MANCARE GATITA ACASA da
CARNE VITA 0
CARNE PORC da
CARNE MIEL 0
CARNE PUI da
ORGANE da
PESTE APA DULCE nu
PESTE APA SARATA nu
PRODUSE SOIA nu
LEGUMINOASE da
BISCUITI / NAPOLITANE / CROISSANTE ocazional
PRODUSE PATISERIE
COVRIGI rar
CHIPSURI / ALTE SNACKSURI rar
CEREALE INTEGRALE nu
CEREALE RAFINATE (paste albe, paine 2 ori pe
alba, orez alb) săpt.
FRUCTE PROASPETE/CONGELATE da
FRUCTE GATITE rar
LEGUME PROASPETE da
LEGUME GATITE rar
LEGUME VERZI/CU FRUNZE VERDE INCHIS nu
CONSERVE LEGUME / FRUCTE nu
CONSERVE PESTE Rar-ton
MARGARINA rar
LAPTE nu
LACTATE (IAURT, UNT) da
BRANZETURI da
OUA da
CARTOFI PRAJITI nu
CARNE PRAJITA da
ALIMENTE CU ZAHAR ADAUGAT Zahăr
brun
INDULCITORI ARTIFICIALI nu
ALIMENTE CU INDULCITORI ARTIFICIALI
NUCI/ SEMINTE/ ALUNE nu
GRASIMI (ULEI, MAIONEZA,UNT,FRISCA) nu

CAT DE DES CONSUMI URMATOARELE BAUTURI

FRECVENTA CANTITATE
TIP BAUTURA CANTITATE SAPTAMANALA
(ZI/SAPT/LUNA) ZILNICA
CAFEA NORMALA zilnic 300ml
CAFEA DECOFEINIZATA
APA PLATA zilnic
APA CARBOGAZOASA nu
SUC NATURAL DE FRUCTE deseori
SUC FRUCTE COMERT rar
BAUTURI CARBOGAZOASE DULCI rar
BAUTURI DE TIP COLA rar
BAUTURI DIETETICE ( CU INDULCITORI nu
ARTIFICIALI)
BAUTURI SPORTIVI (izotonice etc. )
BAUTURI ENERGIZANTE nu
BAZANDU-TE PE FELUL IN CARE MANANCI IN MOD REGULAT, CARE DIN AFIRMATIILE DE MAI JOS TE
REPREZINTA:

_da, uneori__ MANANC REPEDE ___MEMBRII FAMILIEI AU ALTE PREFERINTE

nu___MANANC NEREGULAT ___IMI PLACE SA MANANC

_nu__MANANC PE FOND EMOTIONAL __nu_MANANC PREA MULT

__nu_MANANC NOAPTEA-TARZIU ___MANANC PENTRU CA TREBUIE

__uneori_MANANC CONSTRANS/A DE TIMP __nu_RELATIE NEGATIVA CU MANCAREA

_nu__NU-MI PLACE MANCAREA “SANATOASA” _nu__MA LUPT CU PROBLEME LEGATE DE ALIMENTATIE

_deseori__CALATORESC DES __nu_CONFUZ/A IN LEGATURA CU

ALIMENTATIA

__rar_NU PLANIFIC MESELE/MENIURILE __nu_MANANC FRECVENT LA FAST FOOD

_nu__MANANC CE IMI PICA IN MANA __rar_ALEG GUSTARI NESANATOASE

_nu__ NUMAR CALORIILE __da_RESTRICTIONEZ GRASIMI

_nu__NUMAR GRAMELE DE GRASIME ___RESTRICTIONEZ CALORII

_nu__TIN REGIMURI SLABIT DIN REVISTE ___ALEG ALIMENTELE DUPA INDICELE

GLICEMIC

_da__IAU PASTILE SLABIT __rar_“SAR” PESTE MESE

_nu__MANANC PREA PUTIN __da_MANANC MICUL DEJUN

rar__“RONTAI” INTRE MESE ___da MANANC PUTIN SI DES

_nu__MANANC MULT SI RAR __da_MANANC FRUCTE DUPA MASA

__rar_MANANC DESERT DUPA MASA __NU_CEDEZ USOR TENTATIILOR SI POFTELOR

_da__MA ABTIN DE LA CE POFTESC

CARE CONSIDERI CA SUNT PROBLEMELE/GRESELILE TALE IN ALIMENTATIE?

__________________________
___________________________nu________________________________________________________
_____________________________________________________________________________________
____________

OBICEIURILE ALIMENTARE CARE CONSTITUIE O PROVOCARE PENTRU TINE (obiceiuri bune/sanatoase pe

care incerci sa le
adopti)__________________________________________nu________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________

OBICEIURILE ALIMENTARE DE CARE ESTE MULTUMIT/A

____________________________________________
____________________________da_______________________________________________________
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