Dysphagia Survey for Caregivers/Providers

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1. For whom do you MAKE or PURCHASE pureed foods. Check all that apply.

Spouse

Parent/Relative

Child

Friend

Organization

Other (please specify)

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2. If you are MAKING pureed foods, how often do you make them?

Daily

1-2 times per week

More than 3 times per week

1-2 times per month

Other (please specify)

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3. Which of these pureed foods are you currently MAKING? Check all that apply.

Starch and grains. (Potatoes, rice, etc)

Vegetables

Protein (meat, poultry, fish, tofu, etc)

Dessert

Other (please specify)

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4. Which of these pureed foods are you currently PURCHASING. Check all that apply.

Starch and grains (rice, potatoes, etc)

Vegetables

Protein (Meat, poultry, fish, tofu, etc)

Dessert

Other (please specify)

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5. If you PURCHASE pureed foods, where are you buying them?

Online (please specify in the other section)

In stores (please specify in the other section)

Personal chef

Other (please specify)

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6. How often do you PURCHASE pureed foods?

Daily

1-2 times per week

More than 3 times per week

1-2 times per month

Other (please specify)

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7. Overall, how satisfied is the person eating pureed food they are given? 0 being unsatisfied, and 10 being extremely satisfied.

Clear

i We adjusted the number you entered based on the slider’s scale.

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8. Why did you rate it this way?

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9. Please rate the importance of the following factors when you PURCHASE pureed foods for someone else.

	Not important	A little important	Important	Fairly Important	Extremely important
Nutritional value	Nutritional value Not important	Nutritional value A little important	Nutritional value Important	Nutritional value Fairly Important	Nutritional value Extremely important
Amount of sugar/carbs	Amount of sugar/carbs Not important	Amount of sugar/carbs A little important	Amount of sugar/carbs Important	Amount of sugar/carbs Fairly Important	Amount of sugar/carbs Extremely important
gluten free	gluten free Not important	gluten free A little important	gluten free Important	gluten free Fairly Important	gluten free Extremely important
dairy free	dairy free Not important	dairy free A little important	dairy free Important	dairy free Fairly Important	dairy free Extremely important
nut free	nut free Not important	nut free A little important	nut free Important	nut free Fairly Important	nut free Extremely important
organic	organic Not important	organic A little important	organic Important	organic Fairly Important	organic Extremely important
food presentation, appearance and packaging	food presentation, appearance and packaging Not important	food presentation, appearance and packaging A little important	food presentation, appearance and packaging Important	food presentation, appearance and packaging Fairly Important	food presentation, appearance and packaging Extremely important
price	price Not important	price A little important	price Important	price Fairly Important	price Extremely important

Question Title

10. If available, which of these pureed foods would you mot likely consider purchasing? Check all that apply.

Starch and grains (Potatoes, rice, etc)

Vegetables

Protein (meat, poultry, fish, tofu, etc)

Dessert

Other (please specify)

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11. If available, which of these meal options would you most likely purchase? Check all that apply.

Complete Breakfast meal

Complete Lunch Meal

Complete Dinner Meal

I only want to purchase individual items, such as a protein, starch or vegetable.

Other (please specify)

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12. If available, how often would you consider purchasing these pureed foods?

1-2 times per week

3-4 times per week

5-7 times per week

1-2 times per month

Other (please specify)

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13. What is the most you would be willing to pay for ONE COMPLETE (protein, starch, vegetables and dessert) pureed meal?

Less that $10

$10 -15

$16-20

$21-25

$26-30

$31-40

more than $40

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14. If available, where would you expect to purchase pureed foods. Check all that apply.

In stores

Delivery

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15. What is the most you would be willing to pay for ONE WEEK of deliveries?

Less than $10

$10-20

$21-30

$31-40

$41-50

more than $50

delivery should be free

Question Title

16. Address

Name

Company

Address

Address 2

City/Town

State/Province

Zip/Postal Code

Country

Email Address

Phone Number

Dysphagia Survey for Caregivers/Providers

Question Title

* 1. For whom do you MAKE or PURCHASE pureed foods. Check all that apply.

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* 2. If you are MAKING pureed foods, how often do you make them?

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* 3. Which of these pureed foods are you currently MAKING? Check all that apply.

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* 4. Which of these pureed foods are you currently PURCHASING. Check all that apply.

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* 5. If you PURCHASE pureed foods, where are you buying them?

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* 6. How often do you PURCHASE pureed foods?

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* 7. Overall, how satisfied is the person eating pureed food they are given? 0 being unsatisfied, and 10 being extremely satisfied.

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* 8. Why did you rate it this way?

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* 9. Please rate the importance of the following factors when you PURCHASE pureed foods for someone else.

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* 10. If available, which of these pureed foods would you mot likely consider purchasing? Check all that apply.

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* 11. If available, which of these meal options would you most likely purchase? Check all that apply.

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* 12. If available, how often would you consider purchasing these pureed foods?

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* 13. What is the most you would be willing to pay for ONE COMPLETE (protein, starch, vegetables and dessert) pureed meal?

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* 14. If available, where would you expect to purchase pureed foods. Check all that apply.

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* 15. What is the most you would be willing to pay for ONE WEEK of deliveries?

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* 16. Address

1. For whom do you MAKE or PURCHASE pureed foods. Check all that apply.

2. If you are MAKING pureed foods, how often do you make them?

3. Which of these pureed foods are you currently MAKING? Check all that apply.

4. Which of these pureed foods are you currently PURCHASING. Check all that apply.

5. If you PURCHASE pureed foods, where are you buying them?

6. How often do you PURCHASE pureed foods?

7. Overall, how satisfied is the person eating pureed food they are given? 0 being unsatisfied, and 10 being extremely satisfied.

8. Why did you rate it this way?

9. Please rate the importance of the following factors when you PURCHASE pureed foods for someone else.

10. If available, which of these pureed foods would you mot likely consider purchasing? Check all that apply.

11. If available, which of these meal options would you most likely purchase? Check all that apply.

12. If available, how often would you consider purchasing these pureed foods?

13. What is the most you would be willing to pay for ONE COMPLETE (protein, starch, vegetables and dessert) pureed meal?

14. If available, where would you expect to purchase pureed foods. Check all that apply.

15. What is the most you would be willing to pay for ONE WEEK of deliveries?

16. Address