Eating Habits Questionnaire

This questionnaire will help me gain a better understanding of your current eating and nutrition habits. Your responses will be instrumental in tailoring guidance and support to assist you in reaching your health and wellness goals.

Please keep in mind that there are no right or wrong answers in this questionnaire, and we are not here to pass judgment. Everyone's eating habits and experiences are unique. Your honest responses are crucial for me to provide you with the best possible assistance.

The primary goal is to gather data and information that will enable me to offer personalized advice and recommendations. The more you can share about your current habits, experiences, and mindset regarding eating, the better equipped I will be to provide guidance that aligns with your current situation and health goals.

The information submitted through the Initial Client Assessment Questionnaire is treated with the utmost confidentiality and respect. For more information regarding how the data is collected, stored and used, please see the Privacy Policy.

Thank you for taking the time to complete this questionnaire. Your input is invaluable, and I look forward to helping you on your journey toward improved health and nutrition.

Your Name

Your email address

How does a average day of eating look like for you?

If you are following a specific medical or therapeutic diet, or responded 'Other' to the question above, please provide more infortamtion about your specific diet.

For how long have you followed this way of eating?

What are some of the foods/meals you like the most?

What are some of the foods/meals you don't like?

If you’re less consistent than you’d like to be, what seems to get in the way or knock you off track?

Do you have any known / diagnosed food allergies or intolerances? If yes, what are those?

Do you have any suspected or possible food allergies or intolerances? If yes, what are those?

Field name

Do you have any digestive system complaints right now? If yes, what are those?

Do you feel like you have trouble controlling your appetite / hunger?

Yes, I feel like I always want foodSometimes; it dependsNo

Do you normally struggle with food cravings?

Yes, often Sometimes; it dependsNo, rarely

If yes or sometimes, what do you normally crave?

What do you normally do when you have cravings?

Have you ever noticed any connection between your emotions and your eating habits? If yes, what happens?

Have you ever noticed any connection between stress and your eating habits? If yes, what happens?

If you think about food and eating more than sometimes, what in particular do you think about?

If you feel you’ve eaten too much, what do you do afterwards?

Check all that apply.

Try to eat less at subsequent mealsSkip the following meal(s)Try to exercise to burn it offFeel badTry to get back in control of thingsPurge by vomiting and / or laxativesForget about it and go back to normal eatingKeep eating... what the heck, I already blown it

How often do you normally make meals at home?

0 meals a day1-2 meals a day3-4 meals a day5 or more meals prepared at home

How often do you normally eat meals in restaurants / cafeterias?

0 meals a day1-2 meals a day3-4 meals a dayAll meals eaten in restaurants / cafeterias

Do you like cooking?

YesSometimes, if I have the time / energyNo

If no, what do you NOT like about cooking?

If yes or sometimes, what do you like about it?

Thinking about all that you have written down here, what do you think you might like to start working on or addressing first?

Contact Information

General eating patterns

Food and health

Hunger cues and appetite

Daily habits and environment

Your goals and priorities