Food Choices for Health

Questions marked with an * are required

Exit Survey

* 1) Gender?

a) Male

b) Female

* 2) Age Category

a) 20-29

b) 30-39

c) 40-49

d) 50-over

* 3) Given the dinner choice on a weekday, please select the meal you would prefer ?

a) Hot Dog/Hamburger/Buffalo Wings, French Fries, and a coke with coffee/tea & Apple Pie for desert.

b) Grilled Chicken over Caesar salad, and Iced Tea with coffee,/tea & Fruit Cup for desert.

c) Spaghetti/Lasagna with Meatballs, and Pepsi Cola with coffee/tea & Cheesecake for desert

d) Steak/Pork Chops, Baked Potato, String Beans, and Ice Water with coffee/tea & Cookies for desert.

e) Grilled salmon, Brown Rice, Peas, Mescaline Salad w/Avocado, and Organic Green Tea with coffee/tea & Dark Chocolate for desert.

* 4) Given the dinner choice on a weekend or holiday, please select the meal you would prefer ?

a) Pizza with pepperoni, sausage, and extra cheese, tortellini soup. garlic knots, and a Coke with coffee/tea & cannoli for desert.

b) Mango Salad, Edamame, Tempura, Corn Chowder, and Iced Tea with Vegan Cakes for desert.

c) Honey Glazed Spiral Ham, Pineapple, Delmonico potatoes, String Beans, and Pepsi Cola with coffee/tea & Iced Cream for desert.

d) Szechuan Chicken, Wonton Soup, Eggroll, Fried Rice, BBQ Spare Ribs, and Coke with coffee/tea & Pineapple for desert.

e) Turkey, Cranberry Sauce, Stuffing, Green Beans, Sweet Potato with coffee/tea & Pumpkin Pie for desert.

* 5) Please rate from 1 to 6, most important to least important factor for food choice ?

( ) Health related condition or illness treatment.

( ) Cultural background.

( ) Company influence while at meal or restaurant.

( ) Diet, nutritional value, and or calories.

( ) Cost while purchasing food.

( ) Taste, smell, and or presentation.

* 6) Under which circumstances do you feel you order/prepare most meals ?

a) Order/prepare most meals by planning.

b) Order/prepare most meals by Impulse.

c) Order/prepare most meals by convenience.

* 7) If dieting, what type of diet do you prefer ?

a) Vegetarian diet.

b) Religious faith based diet.

c) Low carbohydrate diet.

d) Weight-Watchers/Nutrisystem diet.

e) Low fat/low calorie diet.

f) Not applicable.

* 8) If dieting, reason for diet ?

a) Appearance and weight management.

b) Existing medical condition or illness ( ex. Diabetes/High Blood Pressure).

c) Energy/Quality of Life (ex. maintain sports or activity level).

d) Job requirement standards.

e) Health or mortality risk ( cholesterol levels, heart disease or stroke).

* 9) If unable to maintain diet, most likely reason ?

a) Unrealistic diet requirements of program.

b) Cost/availability needs of diet foods.

c) Personal/professional responsibilities make diet difficult.

d) Lack of family/friends support.

e) Food cravings.

* 10) If you were to fail to maintain a diet, when do you feel it would be most likely to happen ?

a) Weekday.

b) Weekend/Holiday.