A nutrition questionnaire attempts to analyze an individual’s food habits. It is usually prepared by dieticians or nutrition councilors who help in training people to eat healthily and achieve their fitness goals. More specifically this may be done to relieve digestive problems, allergies, nutrient deficiencies or achieve weight loss.

Nutrition Questionnaire Sample

Your Name:                ____________________________________________________________

Age:                  ____________________       Gender:             __________________

Current Body Weight (lbs)    ______________ Height(in inches):        __________________

Waist (circumference around navels) :        __________________________________________

Chest:               ______________________           Hips:         ________________________

  1. How would you describe your current job?
    1. Sedentary
    2. Mostly sedentary but needs moving from place to place
    3. Moderately active
    4. Highly active
  1. Do you feel tired after walking fast or climbing stairs (Y/N)?        __________________
  1. How many times do you eat in a day


  1. Do you skip breakfast (Y/N/Sometimes/Often)?                       __________________
  1. Please list down your meals and average timing. If you take any snacks in between meals, write them down as well.


  1. Do you usually eat out at hotels, restaurants and canteen? If yes then how many times a week?


  1. Do you consume alcohol? If yes then how many times a week or month?


  1. Do you smoke? If yes then how many cigarettes in a day?                _________________
  1. Do you regularly order pizza, burgers, french fries and other fast foods? If yes then how many times a week?


  1. Do you exercise? If yes then how many days a week?


  1. What is the nature of your exercise?
    1. Cardio
    2. Weight Training
    3. Cardio + weight training
    4. Yoga
    5. Other(specify):   ______________________________________________
  1. Do you suffer from any of the following?
    1. Gas
    2. High blood pressure
    3. Depression
    4. Sleeplessness
  1. When was the last time you checked you blood pressure, cholesterol and blood glucose level? What was the last reading?