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
