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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.

Sample questions

A preview of what’s in the template. Every question is editable before you launch.

25 questions · ~11 min
Q01
Message

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
Multiple Choice

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
Multiple Choice

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
Multiple Choice

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
Multiple Choice

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 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
Dropdown

What is your age?

  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65+
  • Prefer not to say
Q09
Message

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

Q10
Opinion Scale

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

Scale: 17
Min:Not at all consistentlyMax:Very consistently
Q11
Dropdown

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
Multiple Choice

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
Dropdown

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
Multiple Choice

How do you describe your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q15
Dropdown

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
Opinion Scale

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

Scale: 17
Min:Not at all confidentMax:Extremely confident
Q17
Opinion Scale

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

Scale: 17
Min:Not at all usefulMax:Extremely useful
Q18
Dropdown

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
Opinion Scale

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

Scale: 17
Min:NeverMax:Very often
Q20
Opinion Scale

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

Scale: 17
Min:Not at all usefulMax:Extremely useful
Q21
Dropdown

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
Opinion Scale

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

Scale: 17
Min:Not at all usefulMax:Extremely useful
Q23
Dropdown

What is your current employment status?

  • Full-time
  • Part-time
  • Self-employed
  • Student
  • Homemaker / caregiver
  • Retired
  • Unemployed
  • Prefer not to say
Q24
Opinion Scale

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

Scale: 17
Min:Very unlikelyMax:Very likely
Q25
Dropdown

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 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.

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 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.

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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