Nutrition Survey

A summary of the Survey will be shared at a Member Meeting. Please complete by July 8, 2024. Please complete all fields. Thank you.

Name *

First

Last

Email *

Have you modified your diet since finding out that you have heart disease? *

• Yes
• No

Have you modified your diet after attending a Member Meeting on diet? *

• Yes
• No

Has your doctor recommended your current diet? *

• Yes
• No

Have you worked with a dietitian? *

• Yes
• No

What diet do you currently consume? *

• Standard American Diet
• Mediterranean Diet
• Vegan Diet
• Vegetarian Diet
• Whole Foods Plant Based Diet
• Keto Diet
• Carnivore Diet
• Low-carbohydrate Diet
• DASH Diet
• Atkins Diet
• Other Diet

If Other Diet please describe.

How many times a day do you eat? *

Do you feel a plant-based diet can improve your health? *

• Yes
• No

Are animal proteins the only protein source you consume? *

• Yes
• No

If No, list other sources of protein.

How many servings of green leafy vegetables do you eat each day? *

How many servings of fruit do you eat each day? *

How much time do you or your chef spend cooking dinner? *

How often do you eat processed food each day? *

What are good sources of fiber? *

What is your favorite food or dish? *

What food do you think we should avoid? *

Do you take any supplements? *

• Yes
• No

Additional comments or suggestions

Complete Math *

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