• Nutrition Questionnaire Form

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• Name*
• Email*
• Phone*

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• Preferred form of contact*

  Email Phone
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• Gender* Select Female Male Transgender Prefer not to answer
• Height*
• Weight*
• Age Group* Select 20 and under 21-29 30-39 40-49 50-59 60 and over
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• What dietary practice do you follow?*

  Vegan Vegetarian Pescetarian No dietary restrictions
• Please list any allergies you have.*
• Do you follow any other dietary practices?* Select Intermittent Fasting Keto Paleo Low-Carb DASH Plant-based Other
• How often per week do you eat restaurant meals?*
• How often do you add extra salt to your food?*

  Never Rarely Sometimes Always
• How often do you add extra sugar to your food?*

  Never Rarely Sometimes Always
• How many 8-ounce glasses of water do you drink per day?* Select 1 glass 2 glasses 4-5 glasses 5-8 glasses 8-10 glasses 10-15 glasses
• List any supplements you currently take.*
• What would you like to change about your current diet?*