DIETARY QUESTIONNAIRE - balance health programs

Dietary Questionnaire – Pre-Diet Design

For Australian adults (18+) – suitable for metro & rural settings. Please complete honestly so we can tailor your plan.

Full Name

Phone

Date

1) Where do you live (city, regional, or rural)?

2) Who do you live with, and who cooks/shops?

3) Typical weekday (work hours, breaks, commute, exercise)?

4) Usual number of meals/snacks per day?

5) Foods/drinks you particularly enjoy?

6) Foods you dislike/avoid, and why?

7) Allergies/intolerances/sensitivities (e.g., lactose, gluten, FODMAPs)?

8) Faith/cultural practices (halal, vegetarian, fasting, etc.)?

9) Cooking facilities available (stove, oven, microwave, BBQ, air-fryer, hot plate, fridge/freezer)?

10) Confidence with cooking from scratch?

11) Grocery shopping frequency & do you plan/list meals?

12) Access to fresh food where you live (fruit/veg/lean meats/dairy)?

13) Main reasons for a nutrition plan (weight, energy, gut health, performance, medical)?

14) Diets/approaches tried before—what worked/didn’t and why?

15) Regular medications or supplements?

16) Current health issues/conditions (diagnosed or suspected)?

17) Stress & sleep quality ratings (1–10)?

18) Travel frequency & how you manage meals on the road?

19) Where are most meals eaten (home, work, on the road)?

20) Times you struggle with hunger/cravings/low energy?

21) What does “healthy eating” mean to you?

22) Preferred guidance style: detailed plan, flexible guidelines, or visual templates?

23) Motivation to change right now (1–10)?

24) Anything else about your routine or relationship with food?