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1 to 1 nutrition session with Rowan dietetic students
Please fill out this questionnaire below before your 1 on 1 meeting with dietitian student
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What is your first name? *
What is your last name? *
What is your phone number? (xxx-xxx-xxxx) *
What is your household size? *
How many adults over 18 in your household? *
How many children under 17 years and younger in your household? *
What is your email address? *
Is this your first session with a dietetic student through Roots to Prevention? If so, please provide the date and time of your previous meeting *
What is the best time to schedule your 1 on 1 session? (Check all that apply) *
Monday
Tuesday
Wednesday
Thursday
Friday
Morning (8-11am)
Midday (12-3pm)
Evening (4-7pm)
N/A
What would you like to address with the dietician student? (Check all that apply) *
Required
Are you currently being treated for any medical conditions? *
Are you currently taking: (Check all that apply) *
Required
How would you describe your diet? Please explain *
Required
Do you have any food restrictions? If so, please explain below *
Do you have any food allergies? If so, please explain below *
How many days a week do you exercise? *
What are your health and nutrition goals? *
Where did you hear about this 1 on 1 session? *
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