Food Survey
Food Survey
Food Survey
Personal history
What was your first meal of the day? Do you season your foods?
Service Hou Y No Y No
r e e
a a
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Breakfast Natural seasonings
Lunch Table salt
Eleven Oil
Dinner
Collations
Breakfast
Lunch
Eleven
Dinner
Collations
QUESTIONNAIRE
Have you had any special diet_____________________How many_____________
Time_________________ Reason_________________________________
Results_________________________________________________________
Use of medications to lose weight YES__ NO___ Which__________________
How many meals do you eat per day:____
o At home_________________________________
o Out__________________________________
Who prepares your food:_________________________________________
Favorite foods:_______________________________________________
Foods you don't like:_______________________________________________
Foods that cause discomfort:_____________________________________
What time are you most hungry___________________
Take some type of supplement: