First Name
*
Last Name
*
Email
*
Over the past week...
Do you seek comfort in food when you're feeling down, overwhelmed or stressed?
*
No
Sometimes
Mostly
Always
Over the past week...
Do you think about or eat food when you're happy or want to reward yourself?
*
No
Sometimes
Mostly
Always
Over the past week...
Do you use food as a nutritional energy source for your body?
*
No
Sometimes
Mostly
Always
Over the past week...
Have you reduced the time you spend thinking about or planning snacks or meals?
*
No
Sometimes
Mostly
Always
Over the past week...
Are you coping with your feelings without turning to food?
*
No
Sometimes
Mostly
Always
Over the past week...
Can you identify your feelings and emotions?
*
No
Sometimes
Mostly
Always
Over the past week...
Are you letting yourself experience emotions without avoiding them or distracting yourself?
*
No
Sometimes
Mostly
Always
Over the past week...
Are you managing your emotions without help from a crutch?
*
No
Sometimes
Mostly
Always