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Dysphagia Survey for Caregivers/Providers
1.
For whom do you MAKE or PURCHASE pureed foods. Check all that apply.
Spouse
Parent/Relative
Child
Friend
Organization
Other (please specify)
2.
If you are MAKING pureed foods, how often do you make them?
Daily
1-2 times per week
More than 3 times per week
1-2 times per month
Other (please specify)
3.
Which of these pureed foods are you currently MAKING? Check all that apply.
Starch and grains. (Potatoes, rice, etc)
Vegetables
Protein (meat, poultry, fish, tofu, etc)
Dessert
Other (please specify)
4.
Which of these pureed foods are you currently PURCHASING. Check all that apply.
Starch and grains (rice, potatoes, etc)
Vegetables
Protein (Meat, poultry, fish, tofu, etc)
Dessert
Other (please specify)
5.
If you PURCHASE pureed foods, where are you buying them?
Online (please specify in the other section)
In stores (please specify in the other section)
Personal chef
Other (please specify)
6.
How often do you PURCHASE pureed foods?
Daily
1-2 times per week
More than 3 times per week
1-2 times per month
Other (please specify)
7.
Overall, how satisfied is the person eating pureed food they are given? 0 being unsatisfied, and 10 being extremely satisfied.
0
10
Clear
8.
Why did you rate it this way?
9.
Please rate the importance of the following factors when you PURCHASE pureed foods for someone else.
Not important
A little important
Important
Fairly Important
Extremely important
Nutritional value
Not important
A little important
Important
Fairly Important
Extremely important
Amount of sugar/carbs
Not important
A little important
Important
Fairly Important
Extremely important
gluten free
Not important
A little important
Important
Fairly Important
Extremely important
dairy free
Not important
A little important
Important
Fairly Important
Extremely important
nut free
Not important
A little important
Important
Fairly Important
Extremely important
organic
Not important
A little important
Important
Fairly Important
Extremely important
food presentation, appearance and packaging
Not important
A little important
Important
Fairly Important
Extremely important
price
Not important
A little important
Important
Fairly Important
Extremely important
10.
If available, which of these pureed foods would you mot likely consider purchasing? Check all that apply.
Starch and grains (Potatoes, rice, etc)
Vegetables
Protein (meat, poultry, fish, tofu, etc)
Dessert
Other (please specify)
11.
If available, which of these meal options would you most likely purchase? Check all that apply.
Complete Breakfast meal
Complete Lunch Meal
Complete Dinner Meal
I only want to purchase individual items, such as a protein, starch or vegetable.
Other (please specify)
12.
If available, how often would you consider purchasing these pureed foods?
1-2 times per week
3-4 times per week
5-7 times per week
1-2 times per month
Other (please specify)
13.
What is the most you would be willing to pay for ONE COMPLETE (protein, starch, vegetables and dessert) pureed meal?
Less that $10
$10 -15
$16-20
$21-25
$26-30
$31-40
more than $40
14.
If available, where would you expect to purchase pureed foods. Check all that apply.
In stores
Delivery
15.
What is the most you would be willing to pay for ONE WEEK of deliveries?
Less than $10
$10-20
$21-30
$31-40
$41-50
more than $50
delivery should be free
16.
Address
Name
Company
Address
Address 2
City/Town
State/Province
Zip/Postal Code
Country
Email Address
Phone Number