Healthy Habits Questionnaire
What type of breakfast do you have most of the time?
Cereal / pastries
Cooked breakfast (full English)
Coffee / Tea /skip breakfast
Toast
Protein shake / smoothie
Skip breakfast
Other
How often do you skip breakfast?
Never
More than 3 times per week
3 times or less per week
Always
Do you get hungry or tired before lunch?
Yes
No
What do you normally have for lunch?
Fast food / meal deal
Packed lunch / sandwich
Fruit / yogurt
Cooked meal / salad
How long does each meal last on average?
Less than 10 minutes
10-29 minutes
30 to 59 minutes
60 minutes or more
How many times do you chew before swallowing?
Less than 10 times
10 to 19 times
20 to 29 times
30 times or more
When do you have the last meal of the day?
Less than 2 hours before sleeping
More than 2 hours before sleeping
When do you stop eating?
Stop at 80%satiety
Stop at 100% satiety
What will you choose when you want to drink something other than water?
Green tea
Coffee (without sugar)
Black tea (or other kind of tea)
Coffee (with sugar)
Juice (non-carbonated drinks)
Carbonated drinks
What do you use to sweeten your drink or food?
Sugar
Other sweeteners
How often do you snack after dinner?
3 times or more per week
Less than 3 times per week
How often do you exercise
Never
1-2 times a week
3-4 times a week
5-7 times a week
Other
Would you say you are under weight, over weight, just right?
Under weight
Over weight
Just right
Prefer not to answer
Do you have any weight loss or health goals?
Yes
No
Maybe
What goals do you want to achieve?
Weight loss
Inch loss
Tone up
Build lean muscle mass
Get fitter
Other
how would you describe your gender?
Male
Female
non-binary
I would like to skip this question
Prefer to self describe
Your age?
18-29
30-39
40-50
0ver 50
Would you like to know more how we can help you with your goals by making a few small changes?
Yes
No
Maybe
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Submit
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