NOVUS 2024 Food Need Questionnaire
NOVUS Health plans to help patients who don’t always have the food they need OR need help with healthy meals. Regardless of need, please answer these questions so we can plan our programs.
In the last 12 months:
*
We had enough of the kinds of foods we want to eat
We had enough but not always the kinds of foods we want
Sometimes we did not have enough to eat
Often, we did not have enough to eat
In the last 12 months I was worried whether my food would run out before I got money to buy more:
*
Often true
Sometimes true
Never true
In the last 12 months, I couldn't afford to eat healthy and nutritious meals:
*
Often true
Sometimes true
Never true
I can afford healthy food, but need motivation and recipes to choose and prepare nutritious meals:
*
Often true
Sometimes true
Never true
Number of persons in household
*
Number of senior citizens in household (60+)
*
Number of persons under 18 in household
*
If you are interested in more information about our upcoming food program, add your contact information here:
Name
First Name
Last Name
Email
example@example.com
Do you receive food assistance now?
Yes
No
If so, from where?
Submit
Should be Empty: