Name

First Name

Last Name

I spend so much of my life thinking about, choosing and preparing healthy food that it interferes with other dimensions of my life, such as love, creativity, family, friendship, work and school.

Yes

No

When I eat any food I regard to be unhealthy, I feel anxious, guilty, impure, unclean and/or defiled; even to be near such foods disturbs me, and I feel judgmental of others who eat such foods.

Yes

No

My personal sense of peace, happiness, joy, safety and self-esteem is excessively dependent on the purity and rightness of what I eat.

Yes

No

Sometimes I would like to relax my self-imposed “good food” rules for a special occasion, such as a wedding or a meal with family or friends, but I find that I cannot. (Note: If you have a medical condition in which it is unsafe for you to make ANY exception to your diet, then this item does not apply.)

Yes

No

Over time, I have steadily eliminated more foods and expanded my list of food rules in an attempt to maintain or enhance health benefits; sometimes, I may take an existing food theory and add to it with beliefs of my own.

Yes

No

Following my theory of healthy eating has caused me to lose more weight than most people would say is good for me, or has caused other signs of malnutrition such as hair loss, loss of menstruation or skin problems.

Yes

No