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Eating and dietary habits survey - Template

1. My First Page
Q1. How many times a day do you eat?
Q2. Please answer the following according to your particular eating habits?
 YesSometimesNo
I eat a good breakfast
I experience feelings of hunger during the day
I eat meat
I eat vegetables
I eat fruit
I eat dairy
I eat sweets
2.1 I eat a good breakfast

2.2 I experience feelings of hunger during the day

2.3 I eat meat

2.4 I eat vegetables

2.5 I eat fruit

2.6 I eat dairy

2.7 I eat sweets

Q3. What meal would you consider to be your main meal of the day?

Q4. What does your main meal consist of and how is it prepared?
Q5. What does your main meal on the weekend consist of and how is it prepared?

Q6. Have you been avoiding some foods for health reasons?

Q7. Do you have any particular food allergies?

Q8. What is your weekly food intake frequency of the following food categories?
 Several times a dayOnce a daySeveral times a weekLess oftenNever
Sweet foods
Salty foods
Fresh fruit
Fresh vegetables
8.1 Sweet foods

8.2 Salty foods

8.3 Fresh fruit

8.4 Fresh vegetables

Q9. What percentage of your regular diet consists of meat and meat products?
Q10. How much of your diet consists of vegetables and non-animal products?
Q11. Do you or have you ever had cholesterol problems?
Q12. Do you know your current BMI (Body Mass Index) index?




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