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* 1. Where do you receive your Home Delivered Meals from?

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* 2. Age

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* 3. Gender

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* 4. Race

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* 5. How long have you been getting meals?

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* 6. How many meals do you eat every day, including home delivered meals?

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* 7. What do you do for meals on days when meals are not delivered?

  Always Sometimes Never
I cook  easy to fix meals for myself
Family or friends provide meals
I eat at restaurants
I skip meals or eat less food
I eat food saved from other meals

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* 8. Are you satisfied with the...

  Always Sometimes Never
way the food tastes?
way the food smells?
 way the food looks?
variety of foods?
attitude of person who delivers

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* 9. As the result of the home delivered meals program...

  Yes Maybe No
I eat a healthier variety of food
I eat less salt (sodium)
I eat less high fat foods
I can reach/keep a healthy weight
I believe my health has improved and I feel better
I am less hungry during the day
I can continue to live in my own home

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* 10. Additional Comments

T