Template 咨询表格 健康习惯问卷模板

健康习惯问卷模板

健康习惯问卷模板

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Healthy Habits Questionnaire Template

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1.
Which kind of breakfast do you usually have?[多选题]
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?[多选题]
Never
3 times or less per week
More than 3 times per week
Always
3.
Do you feel hungry or tired before lunchtime?[多选题]
Yes
No
4.
What do you typically eat for lunch?[多选题]
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?[多选题]
Less than 10 minutes
10–29 minutes
30–59 minutes
60 minutes or more
6.
How many times do you usually chew before swallowing?[多选题]
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?[多选题]
Within 2 hours before sleeping
More than 2 hours before sleeping
8.
When do you stop eating during a meal?[多选题]
When about 80% full
When completely full (100% satiety)
9.
If you want a drink other than water, which would you choose?[多选题]
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?[多选题]
Sugar
Other sweeteners
11.
How often do you snack after dinner?[多选题]
3 times or more per week
Less than 3 times per week
12.
How often do you exercise?[多选题]
Never
1-2 times a week
3-4 times a week
5-7 times a week
Other
13.
Would you describe your weight as:[多选题]
Underweight
Overweight
About right
Prefer not to answer
14.
Do you have any weight loss or health goals?[多选题]
Yes
No
Maybe
15.
Which goals do you want to achieve?[多选题]
Weight loss
Inch loss
Tone up
Build lean muscle mass
Get fitter
Other
16.
How would you describe your gender?[多选题]
Male
Female
Non-binary
I would like to skip this question
Prefer to self-describe
17.
What is your age group?[多选题]
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?[多选题]
Yes
No
Maybe
*
19.
Name
20.
Phone Number
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Template instructions
健康习惯问卷模板可帮助您收集有关个人饮食、锻炼和日常生活的信息。使用此调查来评估健康行为,确定需要改进的领域,并支持为学生、客户或患者设定目标。

这个免费模板包括有关早餐习惯、膳食类型和持续时间、零食、饮料选择、饱腹感提示、咀嚼频率、运动频率、体重感知和健康目标的问题。年龄和性别等人口统计项目以及联系人字段可让您跟进。

它适合体育教师、健身教练、医疗保健提供者、健康计划和学校。自定义措辞、添加品牌、将表单嵌入网站或共享链接;响应可以导出或与其他工具集成以跟踪进度。在移动设备上收集响应,将结果导出到电子表格,或连接 100 多个集成,以自动化工作流程和跟进,以获得更好的结果。

点击“使用此模板”立即定制并启动您的健康习惯问卷。

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