CXF Client Dietary Evaluation

Hello, thank you for choosing CXF to help guide you on your wellness journey. In order to help improve your nutrition we need a little background information on your eating patterns. Please answer each question honestly with the best of your abilities. No information will be shared without your consent, however may be analyzed and used for future research. Your responses will be linked to an alias in order to ensure anonymity. You protected by the HIPAA Privacy Rule.

I Understand

How many meals do you eat on a typical day?

For Breakfast (Meal 1) I enjoy:

For Lunch (Meal 2) I eat:

For Dinner (Meal 3) I eat:

For extra meals/snacks I tend to have:

I follow serving sizes on packaged foods:

Of Course !

Or Nah !

Days a week I eat fast food:

0

1-2

3-4

5+

Please list any vitamins, supplements, fat burners, you take on a regular basis (be honest):

How many days do you prepare your meals?

Please rate the following which best describe you:

I snack impulsively on whats available

I pack snacks

I dont snack