MO.gov
DHSS Live Well Restaurant Survey for Patrons
1. Why did you choose this restaurant today? Choose all that apply.
*
Type of food
Service
Cleanliness
Healthy options
Convenience
Other
If other:
*
2. How did you find out about this restaurant?
*
Advertisement
Word of mouth
Website
Live Well information/website
Other
Maximum of
250
characters.
Currently Used:
0
characters.
3. Does it matter to you that there are healthy choices available?
*
Yes
No
Maximum of
250
characters.
Currently Used:
0
characters.
4. Would you pay a little more if you knew the food was certified healthy?
*
Yes
No
Maximum of
250
characters.
Currently Used:
0
characters.
5. Will you visit this restaurant again?
*
Yes
No
Maximum of
250
characters.
Currently Used:
0
characters.
6. Please share any additional comments about the Live Well program.
Restaurant
*
Location
*
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