Annie Newbury – Lifestyle Questionnaire Form

Annie Newbury - Lifestyle Questionnaire Form

Instructions:

This questionnaire is to assist your counsellor in deciding how best to help you. Read question carefully before answering. If you have difficulty deciding on a question, choose an answer that is the nearest tothe truth. There is no wrong or right answer. There may be questions you do not wish to or cannot answer and you can simply leave thoseblank for now. IF YOU ARE FILLING IN FROM A COMPUTER, PERHAPS HIGHLIGHT ANSWERS BECAUSE YOU WILL NOT BE ABLE TO TICK THE BOXES

01. Contact Details

Full Name
Address

02. Age last birthday

03. Relationship status (Select Relevant)

04. Any children? (List their ages)

5. Occupation / Job / Career?

06. Job Satisfaction

07. Living Circumstances

08. Education

09. Financial position

10. Active hobbies & interests?

11. Regular exercise to keep healthy?

12. How Would You Describe Your Relationships?

Mother
Sisters:
Children:
Male Friends:
Father:
Female Friends:
Brothers:
Colleagues:
Partner:
Boss:

13. How would you describe yourself?

Humorous:
Practical:
Aggressive:
Moody:
Bored:
Depressed:
Impulsive:
Anxious:
Optimistic:
Confident:
Take risks:
Kind:
Assertive:
Patient:
Perfectionist:

14. Do you have strong religious or spiritual beliefs?

15. Do you have a purpose or mission in life?

Weight and Body Image

16. Your height (ft/in or metres)

17. Current weight (Kg / lbs)

18. What was your maximum weight?

19. What was your minimum adult weight?

20. What weight or size would you like to be?

21. Describe your current weight

22. Your Family’s Weight Details

23. More information on weight & dieting behaviour in your family?

24. Do you feel under pressure to control your weight because of your job or any other reason?

25. Do you feel your weight stops you from doing important things in life?

e.g. being fashionable, finding a mate, playing sport?

26. If you are over or under weight, why do you think this is so?

Body Image

27. What words would you use to describe your body shape?

28. How you feel about aspects of your body?

Current weight:
Shape: (proportions)

29. Have you ever been teased, bullied or rebuked about your body?

30. Have you considered cosmetic surgery?

31. Do you do any of the following?

Weigh yourself:
Check yourself in mirrors:
Measure yourself:
Avoid mirrors:
Smoke for weight control:
Avoid changing rooms :
Use recreational drugs for weight control:
Avoid being photographed

Weight History

32. At what age were you first concerned about your weight?

33. Are you currently trying to lose weight?

34. How has your weight changed?

Since your teens:
During the past year:
During the past month:

35. How many times have you lost & gained weight since your teens?

36. Most weight you have ever lost?

37. History of your eating & weight problems

List any changes to your eating and weight and what else was going on [e.g. I was ill and lost weight aged 5, I was bullied and started buying sweets and eating them in secret, age 8]. Note we will look at this in detail at your assessment

Diets & Dieting

(answer if relevant)

38. How old were you when you first started dieting?

39. What or who prompted you?

40. How often do you begin a new diet?

41. Are you dieting at present?

42. What other activities are you doing to assist weight control?

43. Can you normally maintain a diet?

44. What methods have you used to control your weight in the past?

Untitled

45. Which dieting method(s) did you find most successful?

46. Did you feel capable of eating sensibly when not on a diet?

Eating Patterns

47. Which of these statements feel typical of you at this point in time?

I feel out of control of my eating
I eat large quantities of food in one
I have strong irresistible cravings for certain foods
I vomit when I eat too much
I take laxatives
I eat a lot at night
I exercise every day
I feel bad if I miss exercise
I take laxatives or vomit even without bingeing
I am a nibbler
Once I start eating I feel I can’t stop
Food doesn’t seem to satisfy me
Sometimes I am not even aware of what I eat
I buy special binge foods
I have recently lost a lot of weight
Other people are concerned about my weight loss
Others are concerned about my weight gain
I am ashamed and guilty about my eating habits
I feel proud of my low weight
It is important for me to eat healthy food
I am vegetarian / vegan

48. Frequency of behaviour

(answer only if relevant)

Restricting food:
Bingeing:
Vomiting:
Laxatives:
Diet pills:
Diuretics:
Exercise:
Fasting:
Chewing & spitting:
Weighing:
Smoking:
Alcohol:
Soft drugs:
Hard drugs:

49. When do you find it hard to control your eating?

Morning:
Evening:
Lunch time:
Night:
Afternoon:
Weekends:

50. On which occasions is it hard it control your eating?

(e.g Christmas, being alone, at work, at a restaurant, visiting parents)?

51. Do you eat more before your period?

52. How many bad eating days in the last month?

53. What do you eat on a bad day?

54. What do you eat on a good day?

55. If you eat something you feel you shouldn’t, are you able to stop?

56. Describe your pattern of good and bad days?

(e.g. a few good days followed by 4 or 5 bad days)

57. What sorts of feelings do you have?

58. Where Do You Eat Your Meals?

Breakfast:
Lunch:
Snacks:
Dinner:

59. Who is responsible for preparing the food you eat?

60. Are you able to control your eating when you are not on a diet?

61. Do you often eat out or take-away?

62. Is there any food you cannot/will not eat?

Medical

63. What is your state of health in general?

64. Do you suffer from any of the following medical conditions?

(mark only which apply)

Sore Throats:
Thrush:
Weakness:
Palpitations:
Tiredness:
Blood Pressure:
Seizures:
Rashes:
Stomach Pain:
Insomnia:
Constipation:
Allergies:
The Shakes:
Feeling Cold:
Diabetes:
Sweats:
Dental Trouble:
Asthma:
Headaches:
Migraine:
High Cholesterol:
Had Glandular

65. Have you had any serious mental problem in the past?

66. Have you ever?

Had inpatient treatment for a mental condition?
Seen a mental health specialist for problems?
Used complementary therapies?

67. Do You Take?

(Please select if relevant)

68. Do you often worry about your health?

69. Do you often visit your family doctor?

70. Are you able to take positive action to boost your health?

More about You

Knowing more about you will help us to target the right kind of help for you. There are no right answers so please answer these questions as honestly as you can.

71. Do You?

Trust other people?
Like meeting new people?
Make friends easily?
Enjoy physical signs of affection?
Take criticism well?
Take a compliment well?
Work well with other people?
Have friends you can trust?
Have any friends who confide in you?
Feel attractive to the opposite sex?
Have good dress sense?
Feel comfortable with people?
Feel generally good at what you do?
Feel you can cope in a crisis?
Enjoy learning new things?
Worry in case people dislike you?
Worry about what other people think?
Worry about setbacks a lot?
Take the blame in relationships?
Put yourself last?
Feel intimidated by authority?
Feel taken for granted?
Regret your early sexual life?
Keep your feelings/opinions to yourself?
Apologise often (even if not your fault)?
Spend a lot of time going over the past?

72. Personal Style

Do you believe in fate?
Do you cry at weepy movies or on hearing music?
Do you remember birthdays & anniversaries?
Lie awake at night by worries about work you must do?
Do you wish your parents showed you more affection?
Do you believe that men are emotionally stronger than women?
Do you believe that women are the weaker sex?
Do you think women are more caring than men?
Do you ever feel miserable for no good reason?
Does noise irritate you?
Do you smile and laugh as much as most people?
Do you gamble?
Do you blush easily?
Do you like children?
Are you in the habit of daydreaming?
Are most decisions made for you by others?
Do you vote in elections?
Do you have nightmares?
Do you get flashbacks of bad times?
Do you get less love & affection than you deserve?
Do you believe that crying is a sign of weakness?
Has your temper ever got you into trouble?
Does TV provide most of the highlights in your life?
Do you feel you have more weaknesses than strengths?
Do you drive too fast?
Would you go to jail on a point of principle?
Do you get emotional outbursts rather than logical arguments?
Do you feel you lack willpower?

73. Quality Of Life

Is the quality of your life satisfactory?
Do you feel that you have enough fun in your life?
Do you have as much support as you need from other people?
Do you feel in control of your personal problems?
Does your life as it is have meaning?
Have you made the right choices in life?
Do you look forward to the next year of your life?
Have you fulfilled your ambitions & dreams?
Do you feel that you have the important things of life?

73. Quality Of Life

Significant other
Studies or exams
Parent(s
Friends
Immediate family
Health
Work
Spiritual life

75. Use of social media

(select which apply

75. Use of social media

(select which apply

Privacy Statement: NCFED

Thank you for taking time to complete this questionnaire. It will be read with sympathy and absolute confidentiality. We comply with GDPR guidance regarding our responsibility to safeguard your information as well as the Guidelines of our professional regulatory authorities. As a healthcare provider, we follow the common law duty of confidence, which means that where you have given us information, it is treated as confidential and only shared to provide direct care and then only with your express consent. We ensure the information we hold is kept in secure locations with restricted access to the person you have asked to see. We have put in place suitable physical, electronic, managerial and reasonable security procedures to safeguard and secure your information.

Our full privacy statement, including details of your rights regarding your information, can be found on our website:

https://www.eating-disorders.org.uk or you may ask us to email you a copy at admin@ncfed.com.