A nutrition survey questionnaire covers several aspects of health and nutrition and this type of survey is normally conducted by researchers from the health industry. The objective of the nutrition survey questionnaire is to collect as much information as possible about people’s view on nutrition in their food and healthy living. The information received from the survey is used for aiding medical research and other nutrition related research.

Sample Nutrition Survey Questionnaire:

Name of the Participant: _____________________________

Address: ______________________________________  City:_______________

State: __________________  Zip: ________________

Email: _____________________________

Phone Number: ____________________________

Date of Birth: _________________ (MM/DD/YY)  Gender: _____________ (M/F)

  • Have you ever visited a nutrition professional?

a)      Yes

b)      No

  • How many times in the last 5 years did you visit a nutrition professional?

a)      Once a month

b)      Once in 3 months

c)      Once in 6 months

d)     Once a year

e)      Once in 5 years

f)       Never

  • Which of the following food nutrition patterns have you followed in the last few months?

a)      Drinking milk with reduced fat percentage

b)      Eating deep fried food once a month

c)      Less intake of butter or cheese

d)     Trimming of fat from red meat

e)      Trimming of the skin from poultry products

f)       Replacing cooking oil with olive oil

g)      Others: ___________________________ (Please Specify)

  • Which of the following is an important part of your daily diet?

a)      Protein

b)      Fat

c)      Carbohydrates

d)     Iron

e)      Dietary Fiber

f)       Calcium

g)      Vitamin A and C

h)      All of the above

  • Which of the following high calorie food do you consume every day?

a)      Animal fat

b)      Vegetable fat

c)      Nuts

d)     Peanut Butter

e)      Junk Food

f)       Cheese

g)      Chocolate

h)      Processed meat

i)        Fried food

  • Do you suffer from any of the following medical conditions?

a)      Cholesterol

b)      High Blood Pressure

c)      Obesity

d)     High blood sugar

e)      None of the above