Questionnaire: Nutrition and Wellbeing Department, RD Andrea Hayeck (English)
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Full Name *
Phone Number *
MRN *
What is your health goal?
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Required
How many times per week do you eat fast food, takeout meals, or unhealthy snacks?
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Do you have any food intolerances?
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How many meals do you typically eat per day? *
How often do you eat late at night (within 2 hours of going to bed)?
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How many days per week do you engage in physical activity?
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Indicate your stress level on an average day
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Very Low Stress
Extremely High Stress
On average, how much water do you drink in a day?
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How many caffeinated drinks (coffee, tea, soda, energy drinks) do you consume per day on average?
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On average, how many hours of sleep do you get per night?
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Do you take any vitamin or mineral supplements regularly?
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When was the last time you had a blood test to check for nutrient deficiencies?
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Do you eat when you are triggered by a specific emotion or situation (e.g., stress, anxiety, anger, sadness, boredom, happiness)?
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How often do you eat while doing other activities (e.g., watching TV, working on a computer)? 
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How quickly do you typically eat a meal?
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