Clinical Nutrition Awareness Survey Form
Please answer the following questions to help us understand nutrition knowledge and habits. Your responses are anonymous and help improve nutrition education.
What is your age group?
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
What is your gender?
*
Female
Male
Non-binary
Prefer not to say
What is your highest level of education completed?
*
Please Select
High school or less
Some college
Bachelor’s degree
Graduate degree
Other
How would you rate your overall nutrition knowledge?
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1
2
3
4
5
How often do you read nutrition labels when buying food?
*
Always
Often
Sometimes
Rarely
Never
Which sources do you rely on for nutrition information? (Select all that apply)
*
Healthcare professionals
Family or friends
Websites or blogs
Social media
Books or magazines
Other
How frequently do you consume fruits and vegetables?
*
Every meal
Once daily
A few times a week
Rarely
Never
How confident are you in making healthy food choices?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Which of the following best describes your typical eating pattern?
*
Mostly home-cooked meals
Mostly takeout or restaurant meals
A mix of both
Other
What is one nutrition topic you would like to learn more about?
*
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