0917-0036 RDN Services Survey

Dietitian/Nutritionist (circle one): Jenna Sandra Celena Vicki

Nutrition Clinic Survey Date: ______________

Gender: Age:

___ Male ___ less than 18 years ___ 35-64 years

___ Female ___ 18-34 years ___ 65 years and older

What did you like or not like about your nutrition visit?

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Please rate the following statements using numbers 1-5 based on this scale: Circle your answer.

For each statement below circle the number based on this scale:

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

1. I would recommend this nutrition clinic to my family and friends 1 2 3 4 5

2. Usually, my health is good. 1 2 3 4 5

3. I am sure I can take care of my own health. 1 2 3 4 5

4. All my nutrition questions were answered today. 1 2 3 4 5

5. It is important for me to have a follow-up call. 1 2 3 4 5

6. It is important for me to have the same dietitian/nutritionist for my visits. 1 2 3 4 5

7. We made a goal or plan to improve my eating habits. 1 2 3 4 5

8. After today’s nutrition visit, I understand the importance of healthy eating. 1 2 3 4 5

Any suggestions/comments about today’s nutrition visit?

______________________________________________________________________________

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Date Modified: January 22, 2021