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Nutrition Questionnaire - Beta version
Basic Information
Full Name
Email
What is your current height?
What is your current weight?
What is your desired weight?
Based on your current lifestyle and habits, how long do you think it will take to achieve your desired weight?
Within 1 month
1-3 months
3-6 months
6-12 months
More than 1 year
Lifestyle and Eating Habits
How often do you find yourself eating in response to emotions such as stress, boredom, or sadness?
Never
Rarely
Sometimes
Often
Always
How often do you eat meals while doing other activities (e.g., working, watching TV), rather than focusing on your food?
Never
Rarely
Sometimes
Often
Always
How aware are you of the types and quantities of food you eat throughout the day?
Not aware at all
Slightly aware
Moderately aware
Mostly aware
Completely aware
How much do you enjoy your meals and the act of eating?
Not at all
A little
Moderately
Quite a lot
A great deal (it's a highlight of my day)
How often do you eat at restaurants or try new dining experiences?
0-2 times a month
3-4 times a month
5-6 times a month
7-10 times a month
More than 10 times a month
How often do you use food as a reward or treat for accomplishments?
Never
Rarely
Sometimes
Often
Always
Which sources of protein do you most enjoy or consume regularly in your meals?
What types of vegetables do you include most often in your daily or weekly diet?
What are your go-to carbohydrate choices when planning your meals?
Have you ever tried a nutrition plan before?
Have you ever used GLP-1 medications (e.g., semaglutide or tirzepatide such as Wegovy, Ozempic, Zepbound, or Mounjaro)?
Sleeping Habits
How would you rate the quality of your sleep?
Very poor (difficulty sleeping)
Poor (frequent sleep disruptions)
Fair (occasional disruptions)
Good (mostly restful)
Excellent (well-rested and consistent)
How many hours of sleep do you typically get per night?
Less than 4 hours
4-5 hours
5-6 hours
6-7 hours
More than 7 hours
Family Support
How supportive is your family in helping you achieve your weight loss and health goals?
Not supportive at all (frequent conflicts)
Slightly supportive (occasional conflicts)
Moderately supportive (neutral or mixed support)
Supportive (few challenges)
Very supportive (no conflicts, fully aligned with your goals)
How often do you encounter challenges or conflicts with family members regarding your health goals?
Very frequently (every day)
Frequently (a few times a week)
Sometimes (once or twice a week)
Rarely (a few times a month)
Never (no conflicts)
Exercise
How frequently do you engage in physical activities or exercise?
Rarely
Occasionally (once a week)
Sometimes (2-3 times a week)
Regularly (4-5 times a week)
Very frequently (daily or almost daily)
What are the main reasons preventing you from being more physically active? (Select all that apply)
Lack of time
Physical limitations or health conditions
Lack of motivation
Lack of access to exercise facilities or equipment
Other (please specify)
Specify if other
How would you rate the level of barriers preventing you from being more physically active?
Very high barriers (severe challenges)
High barriers (many challenges)
Moderate barriers (some challenges)
Low barriers (few challenges)
No barriers (no challenges)
Behavioral Eating
How often do you eat due to emotions (e.g., stress, boredom) rather than hunger?
Never
Rarely
Sometimes
Frequently
Always
How often do you eat for reasons other than hunger?
Never
Rarely
Sometimes
Frequently
Always
Dietary Choices
How would you rate the difficulty in making healthier food choices?
Very difficult
Difficult
Moderately difficult
Slightly difficult
Not difficult at all
How frequently do you eat processed, high-sugar, or high-fat foods?
Very frequently (daily)
Frequently (a few times a week)
Sometimes (once or twice a week)
Rarely (a few times a month)
Never
Motivation and Goals
What motivates you the most to work towards weight loss or improving your health? (Select the most relevant reason)
Improving physical appearance
Managing or preventing a medical condition
Boosting energy and overall mood
Enhancing self-confidence
Other (please specify)
How committed are you to making the lifestyle changes necessary for your weight loss and health goals (e.g., changing eating habits, increasing exercise)?
Not committed at all
Slightly committed
Moderately committed
Committed
Fully committed
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