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Dietary Survey Questionnaire
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
Do you follow a specific diet plan?
Please select if you follow a specific diet plan or not.
Yes
No
2
Rate your overall satisfaction with your current diet on a scale of 1 to 10.
Please rate your satisfaction level with your diet by selecting the appropriate number of stars.
3
What is the most common breakfast choice for you?
Please describe your typical breakfast choice.
4
How many servings of fruits and vegetables do you consume daily?
Please specify the number of servings you have in a day.
5
Do you have any food allergies or intolerances?
Please indicate if you have any food allergies or intolerances.
Yes
No
6
On average, how many glasses of water do you drink per day?
Please specify the approximate number of glasses of water you consume in a day.
7
How often do you eat out in a week?
Please indicate the frequency of dining out in a week.
Never
1-2 times
3-5 times
More than 5 times
8
Rate your level of satisfaction with your current snacking habits on a scale of 1 to 10.
Please rate your satisfaction level with your snacking habits by selecting the appropriate number of stars.
9
Do you take any dietary supplements regularly?
Please select if you take any dietary supplements on a regular basis or not.
Yes
No
10
What is your favorite healthy meal? Please describe it.
Please share details about your favorite healthy meal.
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