Please take a moment
to fill out the form below before our call…
How Has Dieting Affected Your Life
Chronically tired, even when sleeping well
Hair falling out, more than usual
Missed or inconsistent menses
Do you feel numb, physically?
Please check all that apply...
Any other PHYSICAL signs you'd like to discuss?
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?
I worry about my eating
I have strict rules about eating
I count: calories, carbs, or other
Good versus Bad Food Thinking
I feel guilty if I eat a ‘bad’ food
I have mood swings
I am afraid of feeling hungry
I am afraid of feeling too full
I don’t trust my body
I am afraid that if I start eating ‘forbidden’ foods, I won’t stop eating.
Fantasize About Food
I am pre-occupied by thoughts of what I eat and don’t eat.
Do you have moods or thoughts of __? Please check all that apply...
Any other Psychological you would like to address?
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.
I avoid physical intimacy
Do you engage this behavior_? Please check all that apply
Any other BEHAVIOR issues you'd like to discuss?