First Name

Last Name

Phone *

Email *

Do you get an instant reward or "hit" as soon as you eat sweet, starchy or refined foods? *

Yes

No

Do you eat 5 or more portions of carbohydrates most days (in addition to sweet things this also includes pasta, bread, potatoes, rice and cereals)? *

Yes

No

Do you often drink sweetened or flavored drinks (including fruit juice and artifiically sweetened drinks)? *

Yes

No

Do you often snack or graze between meals? *

Yes

No

Do you eat a lot of fruit (three or more servings per day)? *

Yes

No

Do you usually have generous portions of carbohydrate-rich foods, getting over 30% of your calories from starchy and refined carbohydrates, including bread, pasta, potatoes, rice and cereals, with most of your meals? (Brown versions still count as starch) *

Yes

No

Do you often eat to make you feel better, for example you are disappointed, under pressure or have had an argument? *

Yes

No

Are you eating large portions? *

Yes

No

Do you often fill unsatisfied, even soon after finishing a meal? *

Yes

No

Does the sight, smell or thought of food often stimulate you to eat, even if you have just finished a meal or are not hungry? *

Yes

No

Do you often lose control and eat much more than you meant to, particularly when eating starches, snacks, junk food, or sweets? (May involve eating until uncomfortable, feeling sick or are actually sick). *

Yes

No

Do you often justify eating by thinking "Just this time", or "Later I will eat better/start the diet/burn it off? *

Yes

No

Is food always on your mind - so you find yourself thinking about food during the day? *

Yes

No

Do you sometimes eat in secret? *

Yes

No

Do you sometimes snack late at night or during the night? *

Yes

No

Do you often feel guilty or ashamed about what you are eating, yet find yourself eating it again soon after? *

Yes

No

Do you often crave carbohydrates or feel shaky, irritable, anxious or sweaty without them? *

Yes

No

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