ealthsmart
WEIGHT LOSS &
GYNECOLOGY
(636) 333-1614
Monday - Thursday
8 am - 5:30 pm
Friday
8 am - 12 pm
Saturday
8 am - 12:30 pm
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Gynecology
E Follow Ups
Food Addiction Questionnaire
Have you ever wanted to stop over-eating and found you just couldn't?
(Required)
Yes
No
Do you constantly think about food or your weight?
(Required)
Yes
No
Do you find yourself attempting one diet after another, with no lasting success?
(Required)
Yes
No
Do you eat differently in private than you do in front of other people?
(Required)
Yes
No
Has a doctor or a family member ever expressed concern about your eating habits or weight?
(Required)
Yes
No
Do you eat large quantities of food at one time (binge)?
(Required)
Yes
No
Is your weight problem due to your snacking all day?
(Required)
Yes
No
Do you eat or snack at night to relax?
(Required)
Yes
No
Do you eat to escape from your emotions or feelings?
(Required)
Yes
No
Do you eat when you're bored?
(Required)
Yes
No
Have you ever hidden food to make sure you will have "enough"?
(Required)
Yes
No
Do you feel driven to exercise excessively to control your weight?
(Required)
Yes
No
Do you frequently feel guilty for eating too much?
(Required)
Yes
No
Do you feel hopeless about your relationship with food?
(Required)
Yes
No
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