すべてのテンプレート
Healthcare & Clinical

Eating Habits, Diet Goals & Barriers Assessment

Measures dietary patterns, nutrition goals, purchasing behavior, and barriers to healthy eating. Use to segment customers, identify unmet needs, and inform food product or service development.

設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全25問・約11分
Q01
メッセージ

Welcome! This survey asks about your eating habits, nutrition goals, and grocery shopping behaviors. It should take approximately 8–10 minutes to complete. Your participation is entirely voluntary and you may stop at any time. There are no right or wrong answers—we are interested in your honest opinions. All responses are confidential and will be reported in aggregate only.

Q02
選択式

Do you currently follow any specific dietary pattern? (Select all that apply.)

  • No specific pattern
  • Vegetarian
  • Vegan
  • Pescatarian
  • Keto or low-carb
  • Low-sugar
  • Gluten-free
  • Dairy-free
  • Halal
  • Kosher
  • Other (please specify)
Q03
選択式

Where do you buy groceries most often? (Select up to 2.)

  • In-store supermarket
  • Online-only grocer
  • Retailer pickup or delivery
  • Meal kit subscription
  • Restaurant or food delivery apps
  • Farmers market or specialty store
  • Other (please specify)
Q04
選択式

What are your top eating goals for the next 3 months? (Select up to 3.)

  • Eat more fruits and vegetables
  • Reduce added sugar
  • Manage weight
  • Build muscle or strength
  • Save time on meals
  • Spend less on food
  • Improve daily energy
  • Manage a health condition
  • Be more environmentally sustainable
  • Try new foods or cuisines
  • Other (please specify)
Q05
選択式

What gets in the way of eating the way you want? (Select all that apply.)

  • Food cost
  • Time to cook
  • Taste preferences
  • Lack of meal planning
  • Limited healthy options nearby
  • Family or household preferences
  • Cravings
  • Stress or mood
  • Portion control
  • Delivery fees or order minimums
  • Short shelf-life of fresh items
  • Confusing labels or nutrition info
  • Other (please specify)
Q06
AIインタビュー

We'd like to learn more about your eating goals and the challenges you face. An AI moderator will ask you a couple of brief follow-up questions.

Q07
自由回答(長文)

Based on your responses in this survey, is there anything else you'd like to share about your eating habits, goals, or challenges?

Q08
プルダウン

What is your age?

  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65+
  • Prefer not to say
Q09
メッセージ

Thank you for completing this survey! Your responses are valuable and will help improve products and services related to nutrition and healthy eating.

Q10
オピニオンスケール

In the last 30 days, how consistently did you follow your dietary pattern?

スケール: 1 – 7
最小:Not at all consistently最大:Very consistently
Q11
プルダウン

In the last 30 days, how many times did you order food or groceries online?

  • None
  • 1–2 times
  • 3–4 times
  • 5–8 times
  • 9 or more times
Q12
選択式

Which of the following approaches would you consider trying to reach your eating goals? (Select all that apply.)

  • Portion control
  • Higher-protein meals
  • Calorie or macro tracking
  • Meal kits with nutrition targets
  • Ready-to-eat healthy options
  • Cutting added sugar
  • Intermittent fasting
  • Working with a nutritionist or coach
  • Meal planning or prepping
  • Other (please specify)
Q13
プルダウン

Of the barriers you selected, which is the single biggest obstacle for you right now?

  • Food cost
  • Time to cook
  • Taste preferences
  • Lack of meal planning
  • Limited healthy options nearby
  • Family or household preferences
  • Cravings
  • Stress or mood
  • Portion control
  • Delivery fees or order minimums
  • Short shelf-life of fresh items
  • Confusing labels or nutrition info
  • Other
Q14
選択式

How do you describe your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q15
プルダウン

In the last 7 days, approximately how many meals did you cook at home?

  • 0
  • 1–3
  • 4–7
  • 8–14
  • 15–21
  • More than 21
Q16
オピニオンスケール

How confident are you that you can maintain your eating changes over the next 30 days?

スケール: 1 – 7
最小:Not at all confident最大:Extremely confident
Q17
オピニオンスケール

How useful would a personalized meal-planning tool be in helping you eat the way you want?

スケール: 1 – 7
最小:Not at all useful最大:Extremely useful
Q18
プルダウン

Where do you currently live?

  • United States
  • Canada
  • United Kingdom
  • European Union
  • Australia / New Zealand
  • India
  • Southeast Asia
  • Middle East / North Africa
  • Sub-Saharan Africa
  • Latin America
  • Other
Q19
オピニオンスケール

In the last 7 days, how often did you snack between meals?

スケール: 1 – 7
最小:Never最大:Very often
Q20
オピニオンスケール

How useful would simplified nutrition labels or scoring be in helping you eat the way you want?

スケール: 1 – 7
最小:Not at all useful最大:Extremely useful
Q21
プルダウン

What is the highest level of education you have completed?

  • High school or less
  • Some college / associate degree
  • Bachelor's degree
  • Graduate or professional degree
  • Other
  • Prefer not to say
Q22
オピニオンスケール

How useful would budget-friendly healthy recipe suggestions be in helping you eat the way you want?

スケール: 1 – 7
最小:Not at all useful最大:Extremely useful
Q23
プルダウン

What is your current employment status?

  • Full-time
  • Part-time
  • Self-employed
  • Student
  • Homemaker / caregiver
  • Retired
  • Unemployed
  • Prefer not to say
Q24
オピニオンスケール

How likely would you be to try an online grocery service that offered features aligned with your eating goals?

スケール: 1 – 7
最小:Very unlikely最大:Very likely
Q25
プルダウン

What is your approximate annual household income?

  • Under $25,000
  • $25,000–$49,999
  • $50,000–$74,999
  • $75,000–$99,999
  • $100,000–$149,999
  • $150,000 or more
  • Prefer not to say

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Combines structured questions (dietary pattern, meal frequency, grocery channels, online ordering) with an open-ended AI follow-up interview that adaptively probes on eating goals and challenges, not just a static form
  • Separates stated barriers from a forced single 'biggest obstacle' ranking, giving clearer prioritization data for product development than a flat multi-select list
  • Tests reactions to specific concept ideas (personalized meal planning, simplified nutrition labels, budget recipes, grocery service features) so results map directly to feature or service decisions
  • Closes with an open-text reflection question plus standard demographics, giving both qualitative color and segmentation variables in one instrument

Jotform

Eating Habits Questionnaire Form Template

A static, ready-to-use form template covering general eating habits questions that can be embedded or shared via Jotform's form builder. It's easy to customize with drag-and-drop fields and integrates with Jotform's broader form ecosystem (payments, notifications, etc.). However, it's a fixed question set with no adaptive follow-up or built-in behavioral segmentation logic.

優れている点

  • Quick to deploy using a familiar drag-and-drop form builder
  • Easy to customize field types and branding
  • Benefits from Jotform's wide integration ecosystem (payment, email, storage)

物足りない点

  • Static question set with no adaptive AI probing or follow-up interview
  • No automated per-response quality scoring
  • No voice AI interview option or guided task/screen-share capability

SurveySparrow

Eating Habits Questionnaire Template For Patients

This template is framed for a clinical/patient healthcare context rather than general consumer product research, so its question set likely leans toward medical history and dietary compliance rather than purchasing behavior or product concept testing. It offers SurveySparrow's conversational chat-style UI, which improves completion experience versus a plain form. It remains a fixed-question template without adaptive interviewing or automated scoring.

優れている点

  • Conversational, chat-style survey format improves respondent engagement
  • Positioned specifically for healthcare/patient use cases
  • Part of a broader survey platform with reporting dashboards

物足りない点

  • No adaptive AI follow-up interview or voice AI interview option
  • No automated per-response quality scoring
  • Patient-focused framing may not map well to consumer product/purchasing research needs

よくあるご質問

「Eating Habits, Diet Goals & Barriers Assessment」テンプレートにはどのような設問が含まれていますか?

すぐに使える設問が25問含まれており、最初の設問は次のとおりです:「Welcome! This survey asks about your eating habits, nutrition goals, and grocery shopping behaviors. It should take appr…」・「Do you currently follow any specific dietary pattern? (Select all that apply.)」・「Where do you buy groceries most often? (Select up to 2.)」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか?

回答者は通常、25問を約11分で回答し終えます。

テンプレートは編集できますか?

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか?

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか?

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

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