Eating Related Form

If you have been advised by the surgery to submit an Eating Related Form please use this form.

Eating Related Form

Eating is essential for health. People eat differently and everyone has different habits and activities related to food. This form is designed to help us, and you, to see if you may need any support related to food as part of your health and wellbeing.

Please take time to answer the questions below as accurately as possible. If you would like to speak to a clinician about any of these questions, or have any concerns, please ask a member of our team, who will be happy to help you. Thank you.

Do you spend time thinking about food?
Do you worry about your weight or how you look regarding your weight?
If you are anxious or upset do you ever increased or decreased your food intake?
Have friends or family ever been concerned about your eating?
Have you ever strictly dieted?
Do you avoid food you think is fattening?
Have you ever counted the calories in food excessively or only eat low-calorie food?
Do you regularly miss meals (fast) to control weight? *
Do you ever exercise excessively, with the intention of burning calories?
Are your goals focused around being thin? *
Are you comfortable with how you look?
Do you consider yourself to be an average weight or think of yourself as larger or thinner?
Do you ever underestimate or deny the amount of food you eat?
Have you ever made yourself vomit after eating? *
Do you have any anxiety about eating?
Do you have low confidence and self-esteem?
Do you set yourself very high standards?
Do you ever have low mood, poor sleep, or have recurrent negative thoughts?
Do you ever feel compelled to carry out repetitive acts to make you feel less anxious or more in control? (OCD)