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)? Maximum answer space: 4 lines.

2) Who do you live with, and who cooks/shops? Maximum answer space: 4 lines.

3) Typical weekday (work hours, breaks, commute, exercise)? Maximum answer space: 4 lines.

4) Usual number of meals/snacks per day? Maximum answer space: 4 lines.

5) Foods/drinks you particularly enjoy? Maximum answer space: 4 lines.

6) Foods you dislike/avoid, and why? Maximum answer space: 4 lines.

7) Allergies/intolerances/sensitivities? Maximum answer space: 4 lines.

8) Faith/cultural practices? Maximum answer space: 4 lines.

9) Cooking facilities available? Maximum answer space: 4 lines.

10) Confidence with cooking from scratch? Maximum answer space: 4 lines.

11) Grocery shopping frequency & meal planning? Maximum answer space: 4 lines.

12) Access to fresh food where you live? Maximum answer space: 4 lines.

13) Main reasons for a nutrition plan? Maximum answer space: 4 lines.

14) Diets/approaches tried before? Maximum answer space: 4 lines.

15) Regular medications or supplements? Maximum answer space: 4 lines.

16) Current health issues/conditions? Maximum answer space: 4 lines.

17) Stress & sleep quality ratings? Maximum answer space: 4 lines.

18) Travel frequency & road meals? Maximum answer space: 4 lines.

19) Where are most meals eaten? Maximum answer space: 4 lines.

20) Times you struggle with hunger/cravings? Maximum answer space: 4 lines.

21) What does healthy eating mean to you? Maximum answer space: 4 lines.

22) Preferred guidance style? Maximum answer space: 4 lines.

23) Motivation to change right now? Maximum answer space: 4 lines.

24) Anything else about your relationship with food? Maximum answer space: 4 lines.