About this template
Understanding a client or patient's daily nutritional intake and lifestyle is the foundation of any successful diet or wellness program. This Eating Habits Questionnaire is designed for dietitians, nutritionists, health coaches, and clinical researchers who need a structured, thorough way to collect dietary histories and lifestyle data.
The form covers everything from meal frequencies and dining-out habits to daily physical activity, sleep patterns, and fluid intake. By gathering this comprehensive baseline data before a consultation, practitioners can spend less time running through basic intake questions and more time building tailored, actionable nutrition plans.
Built for seamless digital use, respondents can easily complete the questionnaire on their phone, tablet, or computer. With Doc2Form, you can instantly turn this template into a live Google Form, collect responses securely, and review organized results in your connected spreadsheet to support client health goals effectively.
Key features
- Comprehensive diet and meal frequency tracking
- Captures daily physical activity and sleep metrics
- Optimized for quick completion on mobile and desktop
- Instant automatic organization in Google Sheets
- Fully customizable questions for specialized clinical needs
Use cases
- Initial client intake for clinical dietitians and nutritionists
- Lifestyle and diet surveys for wellness coaching programs
- Baseline data collection for academic nutrition research studies
- Pre-consultation intake for personal trainers and fitness coaches
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Gender (Dropdown)Select your gender identity.
- Age (Short answer)Enter your current age in years.
- Height (Short answer)Enter your height (e.g., 5'9" or 175 cm).
- Weight (Short answer)Enter your current weight (e.g., 150 lbs or 68 kg).
- Occupation (Short answer)What is your current occupation or daily work setting?
- Weekday Meals Away From Home (Dropdown)How many meals do you typically eat away from home (restaurants, takeout, work cafeteria) Monday through Friday?
- Weekend Meals Away From Home (Dropdown)How many meals do you typically eat away from home on Saturdays and Sundays?
- Hot Meal Frequency (Multiple choice)How often do you eat cooked hot meals per week?
- Night Eating Status (Multiple choice)Do you frequently eat meals or snacks late at night after dinner?
- Coffee and Tea Intake Per Day (Dropdown)Average cups of coffee, black tea, or caffeinated tea consumed daily.
- Alcoholic Drinks Per Week (Dropdown)Approximate number of alcoholic beverages consumed in a typical week.
- Healthy Eating Status (Linear scale)How would you rate the overall quality of your current diet?
- Primary Food Purchase Types (Checkboxes)Select the main categories of food you purchase or consume.
- Hours Sitting Per Day (Short answer)Include desk work, driving, watching TV, etc.
- Hours Standing Per Day (Short answer)Include standing at work or during chores.
- Hours Walking Per Day (Short answer)Include walking for transit, errands, or light exercise.
- Hours Running or Intense Exercise Per Day (Short answer)Include workouts, sports, or high-intensity training.
- Hours Sleeping Per Day (Short answer)Average hours of sleep per night.
- Additional Comments (Paragraph)Share any dietary restrictions, food allergies, medical conditions, or specific health goals you would like us to know.
FAQ
Why is an eating habits questionnaire used?
It helps health professionals, nutritionists, and researchers gather detailed data on an individual's dietary patterns, meal frequencies, and daily activity levels to provide personalized recommendations.
What kind of information does this questionnaire collect?
The form captures basic demographic details, meal frequencies (including dining out and night eating), beverage intake, food purchasing habits, daily physical activity hours, sleep duration, and general health notes.
How do I customize this template for my practice?
Once you convert this template into a Google Form using Doc2Form, you can freely edit, add, or remove questions directly within Google Forms to match your specific clinical or coaching requirements.
Who can use this template?
Registered dietitians, nutritionists, health coaches, personal trainers, wellness clinics, and researchers studying dietary behaviors will find this template especially useful.
How do I share this form with my clients?
You can share the Google Form link via email, embed it on your practice website, or send it directly to clients via messaging apps prior to their initial consultation.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.