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Nutrition Screening
Meal Patterns
How many meals do you typically eat each day?
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Fruit and Vegetable Intake
How many servings of fruits do you consume daily?
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How many servings of vegetables do you consume daily?
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Snacking Habits
How often do you eat snacks between meals?
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Eating Behaviors
How often do you eat more than you intended (overeating)?
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How often do you eat less than you need (undereating)?
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How often do you skip meals?
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Do you find that your eating habits change significantly during social events?
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Do you eat in response to emotions (e.g., stress, sadness, boredom)?
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How often do you eat fast food or takeout meals?
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How often do you eat mindfully (paying attention to the experience of eating)?
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Dietary Restrictions and Preferences
Do you have any dietary restrictions or preferences?
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Nutritional Knowledge and Satisfaction
On a scale of 1 to 10, how would you rate your current level of nutritional knowledge?
(1 = No knowledge, 10 = Very knowledgeable)
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Score:
How satisfied are you with your current eating habits?
(1 = Not satisfied, 10 = Very satisfied)
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Score:
Areas for Improvement
Which areas of your diet do you feel need improvement? (Check all that apply)
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Which areas of your diet do you feel need improvement? (Check all that apply)
Increase fruit and vegetable intake
Reduce overeating
Improve meal regularity
Reduce emotional or social event-driven eating
Other (please specify):
Submit