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Eating Habits and Body Image Self-Reflection (Mental health assessment 1)

A non-diagnostic self-reflection on body image, eating patterns and weight-control behaviours over the past three months.

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Healthcare · Mental health assessment. All Healthcare templates

Questions in this template

About You

  1. Thank you for taking part. These questions look at how you feel about your body and how you have been eating over the past three months. You can skip any question, and your answers are confidential.

  2. This is a self-reflection, not a diagnosis. If eating or body image worries are affecting you, please speak to a doctor or a specialist eating-disorder support service.

  3. How old are you?

    A number from 13 to 99

  4. What is your gender?

    Choose one:

    • Female
    • Male
    • Non-binary
    • Prefer not to say

How You See Your Body

  1. Thinking about the past three months, how much do you agree with each statement?

    • How I feel about myself depends heavily on my weight or shape.
    • I am afraid of putting on weight.
    • I feel uneasy when I see my body, for example in a mirror.
    • I often measure my body against other people's.

    For each row: choose one:

    • Strongly disagree
    • Disagree
    • Neither agree nor disagree
    • Agree
    • Strongly agree

  2. Overall, how satisfied are you with your body?

    Choose one:

    • Very satisfied
    • Satisfied
    • Neither satisfied nor dissatisfied
    • Dissatisfied
    • Very dissatisfied

Eating Patterns

  1. In the past three months, how often have you eaten far more than usual in one sitting while feeling you could not stop?

    Choose one:

    • Never
    • Less than once a month
    • 1-3 times a month
    • About once a week
    • Several times a week

  2. How upsetting have those episodes been for you?

    Condition: Only when such episodes happened

    Choose one:

    • Not at all
    • A little
    • Moderately
    • Very much
    • Extremely

  3. In the past three months, how often have you gone without food on purpose to change your weight or shape?

    Choose one:

    • Never
    • Less than once a month
    • 1-3 times a month
    • About once a week
    • Several times a week

  4. In the past three months, have you used any of these to control your weight? Select all that apply.

    Choose any that apply:

    • Very strict dieting
    • Exercising far more than usual
    • Making yourself sick
    • Laxatives or water pills
    • Diet pills
    • None of these

Impact and Support

  1. How much do concerns about eating or your body get in the way of your daily life?

    Choose one:

    • Not at all
    • A little
    • Moderately
    • A lot
    • Extremely

  2. Have you ever spoken to a health professional about these concerns?

    Choose one:

    • Yes
    • No
    • Prefer not to say

  3. Would you like to receive information about support services?

    Choose one:

    • Yes
    • No

  4. Is there anything else you would like to share? (optional)

    Open answer