Please answer the questions as honestly as you can. There are no right or wrong answers.Eating Habits Questionnaire Client NameDateGeneral eating patternsAs 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 the day and 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)- Select -YesNoIf 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 1-5, how consistent would you say you are with your eating habits?- Select -1 ALL OVER THE PLACE2345 PERFECTLY CONSISTENT, ALL THE TIMEIf you’re less consistent than you’d like to be, what seems to get in the way or knock you off track?Food and healthDo you have any known / diagnosed food allergies or intolerances?- Select -YesNo If yes, what are those?Do you have any suspected or possible food allergies or intolerances?- Select -YesNo If yes, what are those?How often do you have a bowel movement?- Select -More than 3 times daily2-3 times daily1-2 times dailyOnce every 2-3 daysA few times a weekWeekly or lessDo you have any digestive system complaints right now?- Select -YesNo If yes, what are those?Hunger cues and appetiteOn a scale of 1-5, how would you describe your normal appetite / hunger?- Select -1 NEVER HUNGRY2345 ALWAYS STARVING/ RAVENOUSDo you feel like you have trouble controlling your appetite / hunger?- Select -Yes, I feel like I always want food, or eating runs my lifeSometimes; it dependsNoDo you normally struggle with food cravings?- Select -Yes, oftenSometimes; it dependsNo, rarelyIf 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?- Select -YesNoIf yes, what happens? (e.g., When I’m feeling sad I use food to comfort myself; when I’m happy I notice I have fewer cravings)Have you ever noticed any connection between stress and your eating habits?- Select -YesNoIf yes, what happens? (e.g., When I’m stressed I eat more / less)How diligently did you track your food intake/photo journal? Please be honest.- Select -Everyday4-5 days1-3 daysnoneIf you think about food and eating more than sometimes, what in particular do you think about?How often do you eat to the point of being full or stuffed?- Select -Almost constantlySometimesNeverOftenRarelyIf you feel you’ve eaten too much, what do you do afterwards? Check all that apply. Try to eat less at subsequent meals Try to get back in control of things Keep eating… what the heck, already blown it Skip the following meal(s) Purge by vomiting and / or laxatives Try to exercise to burn it off Forget about it and go back to normal eating Feel bad Other:How often do you skip meals or purposely go a long time without eating?- Select -Almost alwaysSometimesNeverOftenRarelyDaily habits and environmentHow often do you normally make meals at home?- Select -0 meals a day1-2 meals a day3-4 meals a dayAll meals prepared at homeHow often do you normally eat meals in restaurants / cafeterias?- Select -0 meals a day1-2 meals a day3-4 meals a day5 or more meals eaten in restaurants / cafeteriasHow often do you shop for food?- Select -More than dailyDailyEvery other dayA couple times a weekOnce a weekLess than once a weekI never shop for food; it just magically appears in my houseOn a scale of 1 to 5, how would you rank your food preparation and cooking skills right now?- Select -1 TERRIBLE / NONEXISTENT2345 EXPERT CHEFDo you like cooking?- Select -YesSometimes, if I have the time / energyNoIf no, what do you NOT like?If yes or sometimes, what do you enjoy about it?Your goals and prioritiesThinking about all that you have answered down here, what do you think you might like to start working on or addressing first?EmailYou will receive a copy of your filled-out worksheet through your email.Submit to Coach
