Nutritional Questionnaire RPM

Have you recently changed your eating habits?

If yes, which ones?

Who cooks at home?

Do you participate in buying groceries?

If yes, how often?

Meal duration

(in minutes)

Breakfast	Lunch	Dinner

What meal do you most often skip and why ?

How hungry are you at meal time? (0 to 3)

(0=not hungry / 1=a little hungry / 2=fairly hungry / 3=very hungry)

Breakfast	Lunch	Dinner

How full are you at meal time? (1 to 3)

(1=still hungry / 2=ok / 3=too full)

Breakfast	Lunch	Dinner

Do you have intense food cravings that lead you to binge?

If yes, why?

Drinking habits

How often do you drink regular juice, iced tea and/or lemonade?

How many cups per day

How often do you drink DIET juice, DIET iced tea and/or DIET lemonade?

How many cups per day

How often do you drink REGULAR soda?

How many cups per day

How often do you drink DIET soda?

How many cups per day

How often do you drink milk?

How many cups per day

How often do you drink water?

How many glasses per day

How often do you drink energy drinks?

How many times per day

How often do you drink regular coffee?

How many cups per day

What do you add to each coffee?

You can check more than one

Sugar
Cream
Milk

How often do you drink DECAF coffee?

How many cups per day

What do you add to each coffee?

You can check more than one

Sugar
Cream
Milk

How often do you drink tea?

How many cups per day

What do you add to each tea?

You can check more than one

Sugar
Cream
Milk

Do you drink alcohol?

e.g. wine, beer, mixed drinks

How many standard drinks do you drink per week?

Eating habits

How often do you eat sweet foods?

e.g. chocolate, candy, cake, pastries, donuts, ice cream, etc.

How often do you eat salty foods?

e.g. chips, popcorn, pretzels, cheesies, etc.

How often do you eat out at restaurants or order take-out meals?

How often do you eat when you are bored, tired, anxious or stressed?

How often do you wake up in the middle of the night and eat?

Drinking habits

Eating habits

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