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* First Name : 
* Last Name : 
Phone : 
 
 
 
Who shops for food at your home?
   
 
 
 
Do you add salt to your food at the table?
 
 
 
Do you eat Breakfast ?
 
Always
 
Sometimes
 
Never
 
 
 
How often do you have home-made food?
 
Always
 
Sometimes
 
Never
 
 
 
Do you try eat healthy when dining out?
 
Almost Always
 
Usually
 
Sometimes
 
Rarely
 
Never
 
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