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1)
How many meals do you eat per day? |
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2)
How many meals do you eat alone in a day? |
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3)
How many servings of fruit do you eat per day? |
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4)
How many servings of vegetables do you eat per day? |
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5)
How many servings of whole or enriched bread, cereal, rice, pasta, noodles, or tortillas do you eat per day? |
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6)
How many servings of milk, cheese, yogurt, or calcium rich soy products do you eat per day? |
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7)
How many servings of high protein food do you eat per day, such as meat,
poultry, tofu, fish, beans, peas, eggs, or nuts? |
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8)
How many drinks of beer, liquor, or wine do you have almost every day? |
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9)
How many glasses of water or other non-alcoholic fluids do you
drink per day? |
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| 10)
Have you gained 10 pounds or more in the last 6 months without trying? |
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10B)
If YES, have you seen a doctor or other professional about your weight gain? |
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| 11)
Have you lost 10 pounds or more in the last 6 months without trying? |
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11B)
If YES, have you seen a doctor or other professional about your weight loss? |
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| 12)
Do you have an illness or condition that made you change the kind and/or amount of food you can eat? |
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12B)
If YES, have you received information necessary to make the necessary food changes? |
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13)
Do you have tooth or mouth problems that make it hard for you to eat? |
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14)
Do you take 3 or more different prescribed or over-the-counter drugs a day? |
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| 15)
Are you physically able to shop for yourself? |
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15B)
If NO, do you have someone who can shop for you? |
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| 16)
Are you physically able to cook for yourself? |
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16B)
If NO, do you have someone who can cook for you? |
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| 17)
Are you physically able to feed yourself? |
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17B)
If NO, do you have someone who can help you? |
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18)
Do you always have enough money or food stamps to buy the food you need? |
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