Medical questionnaire – Eating behavior FM – Eating behavior screening Last name(Required)First name(Required)Date of birth(Required) DD dash MM dash YYYY Check each item that applies to you most of the time.Eating behaviour screening I think my diet could be improved. I regularly eat processed or ultra-processed foods (referred to as foods that have been transformed from their original nature and are usually packaged) For example: foods such as crackers, cookies and cereals, frozen or canned foods, breads and desserts. I frequently eat sweet foods. For example: ice cream, chocolate bars, fruit yogurt, hot chocolate, energy drinks, fruit juices, sodas, candy, bakery products, white or brown sugar, maple syrup or honey, dried fruit, jam, etc. I drink more than 3 coffees a day (1 coffee = 1 cup of black coffee or a double espresso). I drink less than 8 glasses of water a day (or 2L). I rarely eat fruit, or not according to recommendations. I rarely eat vegetables, or not enough as recommended. I don’t cook. I eat few sources of omega-3 (oily fish, sardines, salmon, herring, mackerel, ground flaxseed, flaxseed oil, chia, walnuts, etc.). I rarely eat nuts and seeds (almonds, hazelnuts, walnuts, macadamia nuts, pecans, pistachios, Brazil nuts, pumpkin seeds, sunflower seeds, hemp seeds, etc.). I consume a small amount of extra-virgin olive oil as my main source of fat. I regularly fry or cook food in fat at high temperatures (e.g. deep-frying, stir-frying, searing meat, BBQ, etc.)? I eat starchy foods regularly. For example: pasta, bread, cookies, muffins, bagels, rice, potatoes, breakfast cereals, etc.? I don’t understand food labels (list of ingredients, Nutrition Facts table, etc.). I often feel like I’ve eaten too much, or feel uncomfortable or tired after eating. I have difficulty maintaining a healthy weight. I have a history of yo-yo dieting. I eat quickly and/or in front of the TV or computer. I eat even though I’m not hungry. I snack frequently in the evening. I don’t do grocery shopping. I have teething/chewing problems. I have food allergies or intolerances. Food addiction screening Over the past year, have you eaten more high-carb/sugar foods than you intended at certain times or spent more time eating than you intended to? Have you ever neglected some of your usual daily responsibilities due to eating high carb/sugar foods or overeating? Have you felt like you wanted or needed to reduce your intake of bad sugars over the past year? Has anyone objected to your overconsumption of high carb/sugar foods? Or has your family, friend, healthcare professional, or someone else ever told you they are concerned about your eating habits? Have you ever found yourself concerned about craving foods high in carbs/sugars? Do you often find yourself thinking about foods high in carbs/sugars? Have you ever used foods high in carbohydrates/sugars to relieve emotional discomfort, such as fatigue, irritation, sadness, anger or boredom, etc.? Eating Disorder screening questionnaire (SCOFF) Do you make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone (6.35 kg) in a three-month period? Do you believe yourself to be Fat when others say you are too thin? Would you say Food dominates your life? Are you satisfied with your eating patterns? Do you ever eat in secret? CAPTCHA
