Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Do you feel the food prescription (including educational materials, healthy recipes, and free nutritious foods provided) from OPEN M Food Pharmacy aided you in eating more nutritiously? *

YES

NO

Do you think the food prescription from OPEN M’s Food Pharmacy improved your health and well-being? *

Choose one Response

YES

NO

Did you use the food provided as an alternative to purchasing fast food? *

Choose one Response

YES

NO