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In a typical week, how many meals did you eat out in a restaurant or bring take-out food home to eat?
   
 
 
 
During the past 30 days, did you do any of the following to lose weight or keep from gaining weight? (CHECK ALL THAT APPLY) I did not do anything to lose weight
 
I did not do anything to lose weight or keep from gaining weight
 
Eat less food, fewer calories, or foods low in fat, or low carb diet
 
Eat a low-carb diet
 
Exercise
 
Go without eating for 24 hours
 
 
Take laxatives
 
Smoke cigarettes
 
Bariatric surgery
 
 
Participate in a dietary or fitness program prescribed for you by a health professional
 
Take medications prescribed by a health professional
 
Health coaching
 
 
 
Would you say that in general your health is:
 
Excellent
 
Very good
 
Good
 
Fair
 
Poor
 
 
 
Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
   
 
 
 
2. Do you have one person you think of as your personal doctor or health care provider?
 
Yes, only one
 
More than one
 
No
 
Don't know
 
 
 
What might prevent you from seeing a doctor if you were sick, injured, or needed some type of health care? (CHECK ALL THAT APPLY)
 
Nothing would prevent me
 
Cost
 
Frightened of the procedure or doctor
 
Worried they might find something wrong
 
Cannot get time off from work
 
Hours not convenient
 
Difficult to get an appointment
 
Do not trust or believe doctors
 
No transportation or difficult to find transportation
 
Some other reason
 
 
 
Do you have one person you think of as your personal doctor or health care provider?
 
Yes, only one
 
More than one
 
No
 
Don't know
 
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