Nutrition Check Sheet
Please answer the simple questions.
Today *
MM
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DD
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YYYY
What are you interested in? (multiple answers allowed)
When do you brush your teeth?(multiple answers allowed)
How long does it take when you brush your teeth?
Do you use cleaning devices except toothbrush?
Do you have any diagnosed disease?(multiple answers allowed)
How many kinds of medicine do you take?
Clear selection
Which supplements do you take if you do?(multiple answers allowed)
Do you smoke?
Clear selection
To smokers, How often do you smoke a week?
Clear selection
How long do you sleep usually?
Clear selection
How many times do you eat in a day?
Clear selection
About Appetite(multiple answers allowed)
I eat very often...(multiple answers allowed)
How much do you take some Water?
Clear selection
What kind of drinks do you take often?(multiple answers allowed)
What kind of food do you take often?(multiple answers allowed) *
Required
Do you drink alcohol? *
How often do you take alcohol a week?
How often do you take some sweets a day? *
When do you feel like taking some sweets a day?(multiple answers allowed) *
Required
How often do you take some fruits a day? *
Kindly pick out relevant parts of your mouth condition.(multiple answers allowed)
Kindly pick out of clench and grind your teeth.(multiple answers allowed)
Please tell me about you.(multiple answers allowed)
Name *
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