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Surveys
2013
September
F
Food eaten
Food eaten
0%
Exit Survey
What is today's date?
--
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
--
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
--
2024
Day
-- Select --
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What time is it?
-- Select --
12am
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
12:00pm
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
What have you eaten and drank?
How do you feel?
Very sick (9-10)
sick (6-8)
Uncomfortable (3-5)
Bearly feeling sick (1-2)
Not sick at all (0)
What symptoms are you having? (e.g. cramping, bloated, constipation, etc.)
Other important info:
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