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Phiếu Kiểm Tra Chỉ Số English

This document contains a survey form to collect health and lifestyle information from individuals. The survey asks questions about symptoms, diet, exercise habits, sleep, stress, and other health issues. It collects biometric data like height, weight, and calculates BMI. The results are recorded and compared to body fat standards broken down by age and gender. Contact information is provided for a nutrition club called Sweet Home that is hosting the survey.

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Nga Nguyễn
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26 views1 page

Phiếu Kiểm Tra Chỉ Số English

This document contains a survey form to collect health and lifestyle information from individuals. The survey asks questions about symptoms, diet, exercise habits, sleep, stress, and other health issues. It collects biometric data like height, weight, and calculates BMI. The results are recorded and compared to body fat standards broken down by age and gender. Contact information is provided for a nutrition club called Sweet Home that is hosting the survey.

Uploaded by

Nga Nguyễn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SURVEY FORM OF BODY INDEX

INVITER: PHONE NUMBER:


PUT A TICK ( X ) IF YOUR ANSWERS IS YES:

Do you feel tired, or catch a cold easily? Do you often skip your breakfast?
Do you often : headache, backache, How many glasses of water do you usually
constipation? drink perday?…….
Are you suffering: diabetes, blood pressure, Do you like work-out ?
heart disease?
Do you often feel stress in work? Do you smoke?
Do you have a good sleep? Do you often drink alcohol drink?
Do you often feel hungry and craving for food? Do you want to improve any other health problems?
Do you often eat fast foods (instant noodles, ………………………………………………………………
hot dogs, canned goods, soft drinks, cakes)?
Do you believe that food affects your health?

Full name Sex (M/F) Age

Tel Height Weight

Result
Visceral Bone
Date Subcutaneousfat
fat Mass
BMI Biological
age Muscle Body
shape Water
%

Full name: Age Height


Result
Date Subcutaneous Visceral Bone BMI Biological Muscle Body Water
fat Mass
fat age shape
%

BODY FAT MASS NOTE


FEMALE MALE
GOOD NORMAL MEDIUM BAD GOOD NORMAL MEDIUM BAD STANDARD
WEIGHT WEIGHT Excess Fat STANDARD
VISERAL FAT

18.2 22.1 25.0 >29.6 20-24 10.8 14.9 19.0 >23.3

18.9 22.0 25.4 >29.8 25-29 12.8 16.5 20.3 >24.3

19.7 22.7 26.4 >30.5 30-34 14.5 18.0 21.5 >25.2

21.1 24.0 27.7 >31.5 35-39 16.1 19.3 22.6 >26.1

22.6 25.6 29.3 >32.8 40-44 17.5 20.5 23.6 >26.9

24.3 27.3 30.9 >34.1 45-49 18.6 21.5 24.5 >27.6


If you have any question, please don’t
25.2 28.2 31.8 >35.1 50-54 19.2 22.1 25.1 >28.2
hesitate to contact us:
26.6 29.7 33.1 >36.2 55-59 19.8 22.7 25.6 >28.7 _____________________________
27.4 30.7 34.0 >37.3 60+ 20.2 23.3 26.2 >29.3
NUTRION CLUB: SWEET HOME
ADDRESS: THE HABITAT BÌNH DƯƠNG
APARTMENT NO B3 - 12B -08
PLEASE KEEP THIS RESULT FOR THE NEXT MEETING. THANKS FOR COMING TO OUR NUTRITION CLUB

NOTE: THIS SERVEY IS 100% FREE

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