Template Formulir Konsultasi Templat Kuesioner Kebiasaan Sehat

Templat Kuesioner Kebiasaan Sehat

Templat Kuesioner Kebiasaan Sehat

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20
Questions
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Healthy Habits Questionnaire Template

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1.
Which kind of breakfast do you usually have?[Pilihan Ganda]
Cereal or pastries
Cooked breakfast (full English)
Coffee or tea only
Toast
Protein shake or smoothie
I skip breakfast
Other
2.
How often do you skip breakfast?[Pilihan Ganda]
Never
3 times or less per week
More than 3 times per week
Always
3.
Do you feel hungry or tired before lunchtime?[Pilihan Ganda]
Yes
No
4.
What do you typically eat for lunch?[Pilihan Ganda]
Fast food or meal deal
Packed lunch or sandwich
Fruit or yogurt
Cooked meal or salad
5.
On average, how long do your meals last?[Pilihan Ganda]
Less than 10 minutes
10–29 minutes
30–59 minutes
60 minutes or more
6.
How many times do you usually chew before swallowing?[Pilihan Ganda]
Fewer than 10 times
10 to 19 times
20 to 29 times
30 times or more
7.
When is your last meal relative to bedtime?[Pilihan Ganda]
Within 2 hours before sleeping
More than 2 hours before sleeping
8.
When do you stop eating during a meal?[Pilihan Ganda]
When about 80% full
When completely full (100% satiety)
9.
If you want a drink other than water, which would you choose?[Pilihan Ganda]
Green tea
Black tea or other tea
Coffee (without sugar)
Coffee (with sugar)
Juice (non-carbonated)
Carbonated drinks
10.
What do you use to sweeten food or drinks?[Pilihan Ganda]
Sugar
Other sweeteners
11.
How often do you snack after dinner?[Pilihan Ganda]
3 times or more per week
Less than 3 times per week
12.
How often do you exercise?[Pilihan Ganda]
Never
1-2 times a week
3-4 times a week
5-7 times a week
Other
13.
Would you describe your weight as:[Pilihan Ganda]
Underweight
Overweight
About right
Prefer not to answer
14.
Do you have any weight loss or health goals?[Pilihan Ganda]
Yes
No
Maybe
15.
Which goals do you want to achieve?[Pilihan Ganda]
Weight loss
Inch loss
Tone up
Build lean muscle mass
Get fitter
Other
16.
How would you describe your gender?[Pilihan Ganda]
Male
Female
Non-binary
I would like to skip this question
Prefer to self-describe
17.
What is your age group?[Pilihan Ganda]
18-29
30-39
40-50
Over 50
18.
Would you like to learn how we can help you reach your goals with a few small changes?[Pilihan Ganda]
Yes
No
Maybe
*
19.
Name
20.
Phone Number
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Template instructions
Templat kuesioner kebiasaan sehat membantu Anda mengumpulkan informasi tentang diet, olahraga, dan rutinitas sehari-hari individu. Gunakan survei ini untuk menilai perilaku sehat, mengidentifikasi area untuk perbaikan, dan mendukung penetapan tujuan untuk siswa, klien, atau pasien.

Templat gratis ini mencakup pertanyaan tentang kebiasaan sarapan, jenis dan durasi makan, ngemil, pilihan minuman, isyarat kenyang, frekuensi mengunyah, frekuensi olahraga, persepsi berat badan, dan tujuan kesehatan. Item demografis seperti usia dan jenis kelamin serta bidang kontak memungkinkan Anda menindaklanjuti.

Ini cocok untuk guru pendidikan jasmani, pelatih kebugaran, penyedia layanan kesehatan, program kesehatan, dan sekolah. Sesuaikan kata-kata, tambahkan branding, sematkan formulir di situs web atau bagikan tautan; Respons dapat diekspor atau diintegrasikan dengan alat lain untuk melacak kemajuan. Kumpulkan tanggapan di perangkat seluler, ekspor hasil ke spreadsheet, atau terhubung dengan lebih dari 100 integrasi untuk mengotomatiskan alur kerja dan tindak lanjut untuk hasil yang lebih baik.

Klik "Gunakan Template Ini" untuk menyesuaikan dan meluncurkan kuesioner kebiasaan sehat Anda hari ini.

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