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  2. 2013
  3. September
  4. F
  5. Food eaten
0%
Exit Survey
 
 
What is today's date?
 
 
 
Day
 
 
 
What time is it?
 
 
 
What have you eaten and drank?
   
 
 
 
How do you feel?
Very sick (9-10)
sick (6-8)
Uncomfortable (3-5)
Bearly feeling sick (1-2)
Not sick at all (0)
 
 
 
What symptoms are you having? (e.g. cramping, bloated, constipation, etc.)
   
 
 
 
Other important info: