Diabetes Nutrition Survey Form
Help us understand your nutrition habits, preferences, and support needs related to diabetes. This survey is anonymous and focuses on practical daily routines.
How many main meals do you typically eat per day?
*
1
2
3
4 or more
How often do you include the following foods in your meals?
*
Rows
Never
Rarely
Sometimes
Often
Always
Vegetables
1
2
3
4
5
Whole grains
6
7
8
9
10
Lean proteins
11
12
13
14
15
Fruits
16
17
18
19
20
Sweets/desserts
21
22
23
24
25
What are your primary sources of carbohydrates?
*
Bread/grains
Fruits
Vegetables
Dairy products
Sweets/snacks
Other
How many cups of water do you usually drink per day?
*
Less than 4
4–6
7–9
10 or more
How would you describe your usual meal timing in relation to your glucose monitoring or medication?
*
I eat at set times before/after checking glucose or taking medication
My meal times vary, but I try to coordinate with glucose/medication
I do not coordinate meal times with glucose or medication
How often do you engage in physical activity (walking, exercise, sports, etc.)?
*
Daily
Several times a week
Once a week
Rarely or never
How confident do you feel about making healthy nutrition choices for diabetes?
*
1
2
3
4
5
What is your main nutrition goal right now?
*
Improve blood glucose control
Lose weight
Increase energy
Other
What kind of nutrition support or resources would be most helpful to you?
Meal planning guides
Recipes
Shopping tips
One-on-one coaching
Group support
Other
Is there anything else you’d like to share about your nutrition or support needs?
Submit Survey
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