Health and Nutrition Survey
Please complete this survey to help us understand your health status, nutrition habits, and lifestyle choices. Your responses are confidential and will be used for research and wellness improvement purposes.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Height (cm)
*
Weight (kg)
*
How would you rate your overall health?
*
1
2
3
4
5
On average, how many servings of fruits and vegetables do you eat per day?
*
0-1 servings
2-3 servings
4-5 servings
More than 5 servings
How often do you consume the following foods?
*
Rows
Never
Rarely
Sometimes
Often
Daily
Sugary drinks
1
2
3
4
5
Fast food
6
7
8
9
10
Whole grains
11
12
13
14
15
Dairy products
16
17
18
19
20
Red meat
21
22
23
24
25
How many days per week do you engage in physical activity (at least 30 minutes)?
*
Please Select
0 days
1-2 days
3-4 days
5-6 days
Every day
Do you follow any special diet or have any food allergies?
*
Vegetarian
Vegan
Gluten-free
Lactose intolerant
Nut allergy
No special diet/allergy
Other
How many glasses of water do you drink per day?
*
Please Select
0-2 glasses
3-4 glasses
5-6 glasses
7-8 glasses
More than 8 glasses
How satisfied are you with your current eating habits?
*
Not satisfied
1
2
3
4
5
6
7
8
9
Very satisfied
10
1 is Not satisfied, 10 is Very satisfied
Is there anything else you would like to share about your health or nutrition?
Submit Survey
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