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Food & Eating Questionnaire
Please complete the following form and press 'submit'
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Name
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First
Last
What would you say is/are your main challenge(s) or struggle(s) when it comes to food/eating?
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What is the main area of focus that you would like to work on?
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Complete the following: "I'll know I've succeeded because...."
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How specifically would you like your life/you to be different as a result of working with me?
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Tick any of the following that apply to you:
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Binge Eating
Overeating
Compulsive Eating
Emotional Eating
Comfort Eating
Secret Eating
Obsessive Thoughts About Food/Eating
Cravings
Yo-Yo Dieting
Self-Sabotaging
Tracking Calories/Macros/Points/Syns or similar
Bulimia
Anorexia
Orthorexia
Compensatory Behaviours (e.g. exercise to burn calories, vomiting, laxatives)
Eating During the Nighttime
Other
(Please add details below)
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Tick any of the following that you think contribute to your food/eating issues:
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Anxiety
Depression
Stress
Overwhelm
Tiredness/Fatigue
Poor Diet
Alcohol
Being Alone
Emotions/Mood (e.g. anger, loneliness, happiness, anxiety, stress, boredom, procrastination)
Environment (particular situations, places, adverts or images of food or actual food)
People (particular individuals or groups of people)
Habits (e.g. always having something sweet after a meal)
Time of Day (e.g. eating late at night, when you get home from work/school run, after the children are in bed)
Other
(Please add details below)
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If there is anything else you'd like to add that you think may be helpful for me to know or be aware of then please write in the box below:
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Submit
Home
Rewire Your Food Brain
Testimonials
About
Work With Me
CONTACT
