Eating Habits Questionnaire

Elena Biedert

I’d like to understand more about your current eating and nutrition habits. It’s very important that you answer the questions as honestly as you can. There are no right or wrong answers. I’m not judging you.

All we are doing here is just gathering data and information to help you move towards your goals. The more you can tell me about your current habits, experiences, and mindset around eating, the more I can help.

All the information shared throughout this form is confidential and will be used by me only to provide you the best results. For more information please see our Data Protection Policy.

Name

Email Address

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

Do you have any known / diagnosed food allergies or intolerances? Do you have any known / diagnosed food allergies or intolerances? Yes No

Do you have any suspected or possible food allergies or intolerances? Do you have any suspected or possible food allergies or intolerances? Yes No

How often do you have a bowel movement? How often do you have a bowel movement? More than 3 times daily 2-3 times daily 1-2 time daily Once every 2-3 days A few times a week Weekly or less

Do you have any digestive system complaints right now? Do you have any digestive system complaints right now? Yes No

On a scale of 1-10, how would you describe your normal appetite / hunger? On a scale of 1-10, how would you describe your normal appetite / hunger? 1 - Never hungry 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 feel like you have trouble controlling your appetite / hunger? Yes, I feel like I always want food, or eating runs my life Sometimes; it depends No

Do you normally struggle with food cravings? Do you normally struggle with food cravings? Yes, often Sometimes; it depends No, rarely

Have you ever noticed any connection between your emotions and your eating habits? Have you ever noticed any connection between your emotions and your eating habits? Yes No

Have you ever noticed any connection between stress and your eating habits? Have you ever noticed any connection between stress and your eating habits? Yes No

How often do you think about food and eating (or avoid eating)? How often do you think about food and eating (or avoid eating)? Almost always Often Sometimes Rarely Never

How often do you eat to the point of being full or stuffed? How often do you eat to the point of being full or stuffed? Almost constantly Often Sometimes Rarely Never

If you feel you've eaten too much, what do you do afterwards? Check all that apply. If you feel you've eaten too much, what do you do afterwards? Check all that apply. Try to eat less at subsequent meals Skip the following meal(s) Try to exercise to burn it off Feel bad Try to get back in control of things Purge by vomiting and / or laxatives Forget about it and go back to normal eating Keep eating... what the heck, already blown it Other

How often do you skip meals or purposely go a long time without eating? How often do you skip meals or purposely go a long time without eating? Almost always Often Sometimes Rarely Never

How often do you normally make meals at home? How often do you normally make meals at home? 0 meals a day 1-2 meals a day 3-4 meals a day All meals prepared at home

How often do you normally eat meals in restaurants / cafeterias? How often do you normally eat meals in restaurants / cafeterias? 0 meals a week 1-2 meals a week 3-4 meals a week 5 or more meals eaten in restaurants / cafeterias

How often do you shop for food? How often do you shop for food? More than daily Daily Every other day A couple times a week Once a week Less than once a week I never shop for food; it just magically appears in my house

On a scale of 1-10, how would you rank your food preparation and cooking skills right now? On a scale of 1-10, how would you rank your food preparation and cooking skills right now? 1 - Terrible / Nonexistent 2 3 4 5 6 7 8 9 10 - Expert chef

Do you like cooking? Do you like cooking? Yes Sometimes, if I have the time / energy No

10 + 4 =