Q01
Long Text
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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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
25 questions · ~4 min
Q02
Multiple Choice
Do you currently follow any specific dietary pattern? (Select all that apply.)
Q03
Multiple Choice
Where do you buy groceries most often? (Select up to 2.)
Q04
Multiple Choice
What are your top eating goals for the next 3 months? (Select up to 3.)
Q05
Multiple Choice
What gets in the way of eating the way you want? (Select all that apply.)
Q06
AI Interview
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
Long Text
Based on your responses in this survey, is there anything else you'd like to share about your eating habits, goals, or challenges?
Q08
Long Text
What is your age?
Q09
Long Text
Thank you for completing this survey! Your responses are valuable and will help improve products and services related to nutrition and healthy eating.
Q10
Long Text
In the last 30 days, how consistently did you follow your dietary pattern?
Q11
Long Text
In the last 30 days, how many times did you order food or groceries online?
Q12
Multiple Choice
Which of the following approaches would you consider trying to reach your eating goals? (Select all that apply.)
Q13
Long Text
Of the barriers you selected, which is the single biggest obstacle for you right now?
Q14
Multiple Choice
How do you describe your gender?
Q15
Long Text
In the last 7 days, approximately how many meals did you cook at home?
Q16
Long Text
How confident are you that you can maintain your eating changes over the next 30 days?
Q17
Long Text
How useful would a personalized meal-planning tool be in helping you eat the way you want?
Q18
Long Text
Where do you currently live?
Q19
Long Text
In the last 7 days, how often did you snack between meals?
Q20
Long Text
How useful would simplified nutrition labels or scoring be in helping you eat the way you want?
Q21
Long Text
What is the highest level of education you have completed?
Q22
Long Text
How useful would budget-friendly healthy recipe suggestions be in helping you eat the way you want?
Q23
Long Text
What is your current employment status?
Q24
Long Text
How likely would you be to try an online grocery service that offered features aligned with your eating goals?
Q25
Long Text
What is your approximate annual household income?
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.