FD – Preliminary Questionnaire – Food Dependence Step 1 of 2 – Personal information 0% Personal InformationName(Required) First Name Last Name Date of birth(Required) MM slash DD slash YYYY E-mail(Required) Have you ever suffered or suffer from physical illnesses?(Required) Cardiovascular disease (angina, infarction, stroke, heart attack, bypass, intermittent claudication…) Hypertension (high blood pressure) Diabetes, pre-diabetes, insulin resistance, pregnancy diabetes Polycystic ovary syndrome Lung diseases (asthma, emphysema, COPD…) – (please specify )* Neurological diseases (neuropathies, multiple sclerosis, migraines, Parkinson’s disease…) – (please specify )* Autoimmune or inflammatory diseases (rheumatoid arthritis, type 1 diabetes, systemic lupus erythematosus, scleroderma…) – (please specify )* Dermatological diseases (eczema, psoriasis, lichen plan…) Cancer (please specify )* Gastrointestinal diseases or problems (gastroesophageal reflux, Crohn’s disease, ulcerative colitis, irritable bowel syndrome…) – (please specify )* Memory disorders (Alzheimer’s disease, dementia…) Gynecological diseases, hormonal imbalance… (please specify )* Musculoskeletal diseases (tendinitis, osteoarthritis, osteoporosis…) – (please specify )* Additional Specifications * Have you ever had surgery? Please specify(Required) Are you taking medication? Please specify names and doses(Required) Have you ever suffered or suffer from mental health problems. Describe the difficulty(s), the treatment(s) attempted (drugs, therapies…) and the context, if any, with the year. This includes anxiety, depression, burn-out, adaptation disorder, bipolar affective disease, schizophrenia, toxic or drug psychosis, eating disorder, personality disorder…(Required) Describe any other health problems you have or still have.(Required) Do you smoke or have you ever smoked? (specify the year of start and stop and the number of packs per day please)(Required) Do you drink alcohol? (specify the year of your first drink and stop if so, and the number of drinks per week)(Required) Do you use or have you ever used drugs? (specify which, the year of your first use and when you stopped if this is the case for each substance)(Required) Have you, a loved one or a professional ever thought that your alcohol or drug use was a problem in your life?(Required) Have you ever abused or been addicted to other substances or behaviours (purchases, electronics, gambling, relationships, pornography or other)?(Required) What is your father’s state of health? Physical or psychological illnesses, history of alcohol, tobacco, drugs, obesity or eating disorders (anorexia, bulimia, binge eating)?(Required) What is your mother’s state of health? Physical or psychological illnesses, history of alcohol, tobacco, drugs, obesity or eating disorders (anorexia, bulimia, binge eating)?(Required) What is or was the state of health of your siblings? Physical or psychological illnesses, history of alcohol, tobacco, drugs, obesity or eating disorders (anorexia, bulimia, binge eating)?(Required) In your later family (uncles, aunts, grandparents, cousins), is there a history of alcohol, tobacco, drugs, obesity or eating disorders (anorexia, bulimia, binge eating)?(Required) Describe in a few words your relationship with food, your body and your health?(Required) What have you done over the years to address your problem?(Required) Do you have a particular diet, a specific diet or foods that you avoid?(Required) Do you move, do you exercise regularly? Do you like to move?(Required) How do you sleep?(Required) How do you deal with stress or difficult emotions (tips, habits, professional follow-ups…)?(Required) How old were you the first time you remember hiding for eating, lying or stealing, or just eating to change how you felt?(Required) How tall are you?(Required) How much do you weigh?(Required) Can you give me a short history of your weight through the ages, from your childhood (child round or not), to puberty and then variations in time(Required) What words or emotions come to mind when talking about your relationship with your body, weight, food?(Required) How does your weight problem or relationship with food affect your life (personal, family, social, professional, spiritual)?(Required) What was your relationship with the medical system related to your weight, difficulty with food? Have you felt shame, misunderstanding or even anger, abuse?(Required) How much time, space and energy does your problem occupy in your life/head?(Required) Have you ever thought that you have lost control over what you eat?(Required) Have you ever been told that your weight or what you eat causes you health problems?(Required) Have you ever heard the term “food dependence”? What does it tell you? Do you think you suffer from it?(Required) Do you have anything else you would like to tell me that you think is important?(Required) CAPTCHA
