How has Dieting Affected Your Life

Name*

First Last

Email*

Phone*

PHYSICAL*

Please check all that apply...

Any other PHYSICAL signs you'd like to discuss?

SOCIAL*

I eat differently
I compare my food to what others are eating, such as -Quantity -Type of Food
I worry about what people think about my eating
I worry about what people think about my body
I try to eat the same type and quantity of food that others are eating
I cancel social events because of the food or meals served
I avoid eating
My behavior and beliefs about my eating and body have interfered with relationships

When people are present do you__? Please check all that apply...

An other SOCIAL issues you'd like to discuss?*

PSYCHOLOGICAL*

Do you have moods or thoughts of __? Please check all that apply...

Any other Psychological you would like to address?*

BEHAVIOR*

If I break a food rule, I eat even more of it
If I eat too much, I make up for it by skipping a meal or eating less food, even if I am hungry
I eat more food when I’m feeling stressed
Exercise only to burn calories or lose weight
Talk a lot about dieting, weight, and food?
When I’m on vacation I ignore my food rules and eat whatever I want, no matter how full I feel.
Binge eating.
I avoid physical intimacy

Do you engage this behavior_? Please check all that apply

Any other BEHAVIOR issues you'd like to discuss?*

Please take a moment