BIRTHDATE
FIRST NAME
MIDDLE NAME
ADDRESS
2.
3.
4.
5.
MM
DD
PLACE BARCODE
STICKER HERE
YYYY
RELIGION
No
(Continuation)
Dessert
Cake
Ice Cream
Fruit
Salad
Others, please specify ____________________
Beverage
Canned Juice
Coffee
Soda (regular or light)
Spouse
Yourself
Spouse
Yourself
Dining Out
When you are in a restaurant, what do you usually order?
Soup
Cream-based
Clear Soup
Vegetable
Sauted
Salad
Stir-fried
Dessert
Cake
Ice Cream
Fruit
Salad
Others, please specify ____________________
Beverage
Canned Juice
Iced Tea
Tea
Coffee
Fresh Juice Water
Soda (regular or light)
If with sugar, is it
Table sugar Artificial
Others, please specify _________
At Home
What do you usually eat at home?
Soup
Cream-based
Clear Soup
Vegetable
Sauted
Salad
Stir-fried
Iced Tea
Tea
Fresh Juice Water
If with sugar, is it
Table sugar Artificial
Others, please specify ____________________
7.
8.
Yes
No
3 times
____ Chicken
____ Pork
___ Others, please specify _______
MED-FRSF-NNM-006
NMS STAFF-IN-CHARGE
Rev1Iss2 02-Mar-2012