Diet Questionnaire


Diet questionnaire is a set of questions which are asked by  medical practitioners and some medical agencies from a patient to know his diet pattern so that further course of treatment can be followed accordingly. These questionnaire’s are also undertaken by individual’s personlally so as to determine the diet which he or she needs to follow to keep themselves healthy and fit. It is always advisable for a health conscious person to take these questionnaire every now and then to constantly stay updated on these fonts..

Diet questionnaire Sample

Name of the person

____________________________________

Contact Address

____________________________________

Age

____________________________________

Weight

Q1. How do you rate your health observing the present?

a.Good

b.Fair

c.Poor

d.Very Poor

Q2. What do you think is the reason for the answer in 1 above?

____________________

Q3. Which particular food you enjoy the most?

a.Non veg food items

b.Hot drinks

c.Cold drinks

d.Veg food items

Q4. Do you have a proper sleeping pattern? _____________

If no, state why?___________________

Q5. Do you find enough time for yourself to do any kind of physical exercise? __________

If yes, state in which ways__________________

If no, state why___________________

Q6. Do you think you always stay under stress? __________

If yes, state in which ways__________________

Q7. What do you do to feel relaxed? __________________

a. Eat a lot

b. Go Shopping

c. Watch a movie

d. Do physical excersice

Q8. What is your favorite food? __________________

Q10. Tick from the list of fast foods which you consume frequently.

a. Potato chips

b. Burger

c. Sandwitch

d. Chicken Lollypop

Q11. Do you think you need to loose weight?

a. No

b. Yes

Category: Medical Questionnaire

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