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.
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)
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)
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)
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)
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.
Based on your responses in this survey, is there anything else you'd like to share about your eating habits, goals, or challenges?
What is your age?
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65+
- Prefer not to say
Thank you for completing this survey! Your responses are valuable and will help improve products and services related to nutrition and healthy eating.
In the last 30 days, how consistently did you follow your dietary pattern?
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
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)
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
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
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
How confident are you that you can maintain your eating changes over the next 30 days?
How useful would a personalized meal-planning tool be in helping you eat the way you want?
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
In the last 7 days, how often did you snack between meals?
How useful would simplified nutrition labels or scoring be in helping you eat the way you want?
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
How useful would budget-friendly healthy recipe suggestions be in helping you eat the way you want?
What is your current employment status?
- Full-time
- Part-time
- Self-employed
- Student
- Homemaker / caregiver
- Retired
- Unemployed
- Prefer not to say
How likely would you be to try an online grocery service that offered features aligned with your eating goals?
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
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.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- 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 TemplateA 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.
What it does well
- 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)
Where it falls short
- 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 PatientsThis 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.
What it does well
- Conversational, chat-style survey format improves respondent engagement
- Positioned specifically for healthcare/patient use cases
- Part of a broader survey platform with reporting dashboards
Where it falls short
- 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
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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