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Eating Habits and Body Image Self-Reflection (Mental health assessment 2)

Non-diagnostic reflection on eating patterns, food preoccupation, body image and wish for support, for teens and adults.

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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 help you reflect on eating and body image; they are not a diagnosis. If anything here worries you, a doctor or counsellor can help.

  2. Which age group are you in?

    Choose one:

    • Under 16
    • 16-17
    • 18-24
    • 25-34
    • 35-49
    • 50 or older

  3. What is your gender?

    Choose one:

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

Eating Patterns

  1. Over the past four weeks, how many meals have you eaten on a typical day?

    A number from 0 to 10

  2. Over the past four weeks, how often has each of these happened?

    • I skipped a meal on purpose
    • My eating felt out of my control
    • I followed strict rules about what or when I could eat
    • I felt guilty after eating
    • I tried to make up for eating by exercising hard or eating less

    For each row: choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Always

  3. On a typical day, how much of your time do thoughts about food, eating or weight take up?

    Choose one:

    • Hardly any
    • A little
    • A fair amount
    • Most of the day

  4. Has your weight changed over the past three months?

    Choose one:

    • Lost a lot
    • Lost a little
    • Stayed about the same
    • Gained a little
    • Gained a lot
    • Not sure

Body Image and Wellbeing

  1. How far do you agree with each statement?

    • I feel comfortable with my body
    • How I feel about myself depends heavily on my shape or weight
    • I avoid some situations because of how I look
    • I often compare my body with other people's

    For each row: choose one:

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

  2. How much do concerns about eating or your body get in the way of daily life, such as work, study or seeing friends?

    Choose one:

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

  3. How often does your mood change how much or what you eat?

    Choose one:

    • Never
    • Rarely
    • Sometimes
    • Often
    • Always

Support

  1. Have you ever talked to a health professional about eating or body image?

    Choose one:

    • Yes
    • No

  2. Would you like some support with eating or body image?

    Choose one:

    • Yes
    • No
    • Not sure

  3. What kind of support would you find helpful? Select all that apply.

    Condition: Shown to people who want or may want support

    Choose any that apply:

    • A doctor
    • A counsellor or psychologist
    • A dietitian
    • A support group
    • Online information
    • Other

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

    Open answer

  5. Thank you. If you are struggling with eating or how you feel about your body, please speak to a doctor or a specialist eating-disorder helpline in your country.