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Questions marked with an * are required Exit Survey
 
 
How often do you  add fresh fruits and vegetables to your diet?
 
Daily
 
Weekly
 
Monthly
 
Never
 
 
 
Have you tried new sources of lean protein this week
 
Yes
 
No
 
 
 
Have you shopped for fresh fruits and vegetables this week?
 
Yes
 
No
 
Plan to soon
 
 
 
Do you need assistance in planning your daily menu?
 
Yes
 
No
 
 
 
Do recipes help you in preparing new food items?
 
Yes
 
No
 
Sometimes
 
 
 
Would you contact the Nutritional Educator if you were having trouble with your diet?
 
Yes
 
No
 
 
 
Does your caregiver offer you various food choices?
 
Yes
 
No
 
Sometimes
 
 
 
Do you have reliable transportation to grocery shop?
 
Yes
 
No
 
Sometimes
 
 
 
Have you been able to manage the cost of added fruits and vegetables to your diet?
 
Yes
 
No
 
Sometimes
 
 
 
* Do you feel you are getting enough to eat?
 
Yes
 
No
 
Sometimes
 
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