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  2. 2015
  3. June
  4. I
  5. Initial Nutrition Data
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Are you a patient?
 
Yes
 
No
 
 
 
What is your age?
 
 
 
What is your gender?
 
Male
 
Female
 
 
 
Height:
   
 
 
 
Weight?
   
 
 
 
BMI:
   
 
 
 
BMI category:
 
Underweight
 
Healthy weight
 
Overweight
 
Obese
 
Morbidly Obese
 
 
 
Waist circumference?
   
 
 
 
Are you a caretaker for one or more children?
 
Yes
 
No
 
 
 
Age of Child A?
   
 
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