Eating Habits

Hi there! I'm so glad you're here.

Please answer the questions as honestly as you can. There are no right or wrong answers.

Ready? Let’s begin.

Name

Phone Number

General eating patterns As best as you can remember right now, tell me generally about an average day of eating and drinking. This doesn’t have to be perfect; just capture your usual patterns. Time of day what might you normally eat / drink?

Right now, are you following any particular diet or style of eating? (e.g., vegetarian / vegan, Paleo, kosher / halal, low-carb)

If yes, what? And for how long have you followed this way of eating?

What are some of the foods or meals you like MOST?

What are some of the foods or meals you DON’T like?

Right now, on a scale of 1–10, how consistent would you say you are with your eating habits? All over the place 1 2 3 4 5 6 7 8 9 10 perfectly consistent.

If you’re less consistent than you’d like to be, what seems to get in the way or knock you off track?

Food and health Do you have any known / diagnosed food allergies or intolerances? Y N If yes, what are those?

Do you have any suspected or possible food allergies or intolerances? If yes, what are those?

How often do you have a bowel movement?

Do you have any digestive system complaints right now? If yes, what are those?

Hunger cues and appetite On a scale of 1-10, how would you describe your normal appetite / hunger? NEVER HUNGRY 1 2 3 4 5 6 7 8 9 10 ALWAYS STARVING/ RAVENOUS

Do you feel like you have trouble controlling your appetite / hunger?

Do you normally struggle with food cravings?

If yes or sometimes, what do you normally crave?

What do you normally do when you have cravings?

Have you ever noticed any connection between your emotions and your eating habits? If yes, what happens?

Have you ever noticed any connection between stress and your eating habits? If yes, what happens?

How often do you think about food and eating (or avoiding eating)?

How often do you eat to the point of being full or stuffed?

If you feel you’ve eaten too much, what do you do afterwards? Select all that apply.

How often do you skip meals or purposely go a long time without eating?

How often do you normally make meals at home?

How often do you normally eat meals in restaurants / cafeterias?

How often do you shop for food?

On a scale of 1 to 10, how would you rank your food preparation and cooking skills right now? TERRIBLE / NONEXISTENT 1 2 3 4 5 6 7 8 9 10 EXPERT CHEF

Do you like cooking?

If no, what do you NOT like?

If yes or sometimes, what do you enjoy about it?

Your goals and priorities Thinking about all that you have written down here, what do you think you might like to start working on or addressing first?

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