Dr. Danenberg's Questionnaire - PART 1
Please answer the questions below to the best of your ability. Thank you!

Understanding Your Mouth

Understanding Your Body
36. How many times per week do you eat the following meals outside your home?
 Number of times per week
46. Please record the following measurements in centimeters with a tape measure:
 In inches
Waist circumference (the smallest circumference at or above your belly button):
Hip circumference (the fullest circumference around your buttocks area):
47. In order to improve your health, how willing are you to
 1 - Not willing2 - Somewhat willing3 - Would consider4 - Willing5 - Very willing
Signficantly modify your diet:
Modify your lifestyle (ex: work demands, sleep habits, meal preparation):
Engage in regular exercise/physical activity:
Have periodic lab tests to assess your progress:
Keep a 3-day record when requested of everything you eat and drink:
Powered byFormsiteReport abuse