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EATING HABITS INTAKE FORM
Name
Date
How many meals do you eat per day?
Do you snack?
Yes
No
When do you eat the most? (i.e. At night, when stressed)
Do you find yourself eating even when you are not hungry?
Yes
No
How do you eat?
Quickly
Slowly
What are your favorite foods?
How much water do you drink per day? (how many 8oz. glasses)
Typically what do you eat for:
Breakfast
Lunch
Snack
Dinner
Do you eat fast food?
Yes
No
If you answer Yes above please specify what and how many times per week.
Do you eat frozen already prepared foods?
Yes
No
If you answered Yes above, please specify what and how many times per week.
Do you drink alcohol?
Yes
No
If you answered Yes above, please specify what type of alcoholic beverage and how many times per week.