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Healthy Habits Questionnaire Template

Healthy Habits Questionnaire Template

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Healthy Habits Questionnaire Template

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1.
Which kind of breakfast do you usually have?[Checkboxes]
Cereal or pastries
Cooked breakfast (full English)
Coffee or tea only
Toast
Protein shake or smoothie
I skip breakfast
Other
2.
How often do you skip breakfast?[Checkboxes]
Never
3 times or less per week
More than 3 times per week
Always
3.
Do you feel hungry or tired before lunchtime?[Checkboxes]
Yes
No
4.
What do you typically eat for lunch?[Checkboxes]
Fast food or meal deal
Packed lunch or sandwich
Fruit or yogurt
Cooked meal or salad
5.
On average, how long do your meals last?[Checkboxes]
Less than 10 minutes
10–29 minutes
30–59 minutes
60 minutes or more
6.
How many times do you usually chew before swallowing?[Checkboxes]
Fewer than 10 times
10 to 19 times
20 to 29 times
30 times or more
7.
When is your last meal relative to bedtime?[Checkboxes]
Within 2 hours before sleeping
More than 2 hours before sleeping
8.
When do you stop eating during a meal?[Checkboxes]
When about 80% full
When completely full (100% satiety)
9.
If you want a drink other than water, which would you choose?[Checkboxes]
Green tea
Black tea or other tea
Coffee (without sugar)
Coffee (with sugar)
Juice (non-carbonated)
Carbonated drinks
10.
What do you use to sweeten food or drinks?[Checkboxes]
Sugar
Other sweeteners
11.
How often do you snack after dinner?[Checkboxes]
3 times or more per week
Less than 3 times per week
12.
How often do you exercise?[Checkboxes]
Never
1-2 times a week
3-4 times a week
5-7 times a week
Other
13.
Would you describe your weight as:[Checkboxes]
Underweight
Overweight
About right
Prefer not to answer
14.
Do you have any weight loss or health goals?[Checkboxes]
Yes
No
Maybe
15.
Which goals do you want to achieve?[Checkboxes]
Weight loss
Inch loss
Tone up
Build lean muscle mass
Get fitter
Other
16.
How would you describe your gender?[Checkboxes]
Male
Female
Non-binary
I would like to skip this question
Prefer to self-describe
17.
What is your age group?[Checkboxes]
18-29
30-39
40-50
Over 50
18.
Would you like to learn how we can help you reach your goals with a few small changes?[Checkboxes]
Yes
No
Maybe
*
19.
Name
20.
Phone Number
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Template instructions
Healthy habits questionnaire template helps you gather information about individuals' diet, exercise and daily routines. Use this survey to assess healthy behaviors, identify areas for improvement, and support goal setting for students, clients, or patients.

This free template includes questions about breakfast habits, meal types and duration, snacking, beverage choices, satiety cues, chewing frequency, exercise frequency, weight perception, and health goals. Demographic items such as age and gender plus contact fields let you follow up.

It suits physical education teachers, fitness trainers, healthcare providers, wellness programs and schools. Customize wording, add branding, embed the form on a website or share a link; responses can be exported or integrated with other tools for tracking progress. Collect responses on mobile devices, export results to spreadsheets, or connect with over 100 integrations to automate workflows and follow-up for better outcomes.

Click "Use This Template" to customize and launch your healthy habits questionnaire today.

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1

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2

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3

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