Name: Elite Medical Skin and Laser Center
Price range: $$$

How many meals do you eat daily?

Do you like to snack? If Yes, what are your favorite snacks?

Do you drink alcohol? If Yes, how much?

I usually go out or take out meals (restaurant or fast food) Check all that apply

How many days a week do you eat home cooked meals for dinner?

Who does the shopping and cooking for the family?

What time do you usually take lunch at and for how long?

I often skip breakfast:

I travel often:

Do you ever eat for reasons other than hunger? Please check all that apply

What foods would you describe as your staple foods (eat almost on a daily basis)

Number of times per week you eat the following Traditional American cuisine:

Number of times per week you eat the following Italian cuisine:

Number of times per week you eat the following Mexican cuisine:

Number of times per week you eat the following Chinese/Japanese/Thai/Korean cuisine:

Number of times per week you eat the following Asian/Indian cuisine:

Number of times per week you eat the following Indian Vegetarian cuisine:

Number of times you eat something other than what is listed above:

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