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1. First name: (Required.)

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2. Last name: (Required.)

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3. Preferred email address:

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4. Residential address for mailing participant guide: (Required.)

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5. Current weight (round up the the nearest whole number):

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6. Please rate the following: (Required.)

  Poor Average Good
Energy Level
Sleep

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7. Servings of fiber foods per day (fruits, vegetables, whole grains, beans, nuts/seeds): (Required.)

  0 servings 1-2 servings 3-4 servings 5+
Fruit = 1 medium whole fruit, 1 cup cut-up fruit, 1/2 cup dried fruit
Vegetables = 2 cups raw leafy salad greens, 1 cup cut-up vegetables
Whole Grains = 1 slice of bread, 1/2 cup cooked rice, pasta or cereal
Beans = 1/2 cup cooked beans
Nuts/Seeds = 1/4 cup

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8. I feel confident in my ability to make over meals to increase daily fiber content:

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9. Anything else you'd like us to know?

T