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A food addiction brief screen based on ICD-10 criteria

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* 1. Age

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* 2. Gender

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* 3. How would you describe your ethnicity?

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* 4. What is your weight in kgs?

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* 5. what is your height in cms?

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* 6. What is your waist circumference between the bottom of your ribs and the top of your hips in cms?

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* 7. What is your latest HBA1c in mm/mol (optional)

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* 8. Please list any medications that you are currently taking here (optional)

Have you CRAVED certain foods or drinks?
This is a questionnaire to assess whether you experience cravings for certain foods and drinks that might make it difficult for you to sustain changes to your diet.
Spend a few minutes thinking about any foods or drinks you struggle to control your intake of, typical examples are sweet foods and drinks, high carbohydrate and processed foods.

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* 9. Write the foods and drinks you CRAVE here

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* 10. Have you ever had such a strong desire or sense of compulsion at the thought of having these foods or drinks, that you could not resist the urge to consume them? Choose one answer from the list.

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* 11. Have you ever noticed that you need increasing amounts of these foods or drinks to get the same effect compared to when you first had them?

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* 12. Have you ever noticed that you neglect planning activities because you are too tired, sick or pre-occupied due to these foods or drinks?

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* 13. Have you ever consumed more of these foods or drinks than you intended on more than one occasion?

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* 14. Have you ever experienced at least two of the following withdrawal symptoms when you cut down or stopped consuming these foods or drinks?

Headache, nausea/vomiting, anxiety, depressed/low mood, irritability, shakes, sweating, heart racing/palpitations, fast or shallow breathing, diarrhoea/constipation, sleep disturbance.

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* 15. Have you ever continued to consume these foods or drinks despite you or someone else believing that difficulties with weight gain, diabetes, memory, concentration, anxiety, mood swings, depression, panic attacks or other physical or mental health problems could be due to your consumption of these foods and drinks?

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* 16. Thank you!

0 of 16 answered
 

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