RDN Services Survey

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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?
______________________________________________________________________________
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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