Intuitive Eating with Diabetes Group Questionnaire
There are no right or wrong answers. This form gives us an idea of your starting point. After you have completed the Intuitive Eating Group, we will ask you to complete this form again. This will allow us to better understand your progress. Thank you
Name
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First Name
Last Name
First Name
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First Name
Date completed
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Section 1: Diabetes Distress, Emotional Burden and Diabetes Self Care
Indicate the degree to which each of the following 13 questions may be bothering you in your life, NOT merely if it is true for you, if it is not a bother/problem you might choose “1”. If it is very bothersome to you, you might choose “6”.
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Not a problem (1)
A slight problem (2)
A moderate problem (3)
Somewhat serious problem (4)
A serious problem (5)
A very serious problem (6)
1. Feeling like diabetes is taking up too much of my mental and physical energy
everyday
2. Feeling angry, scared and/or depressed when I think about living with diabetes
3. Feeling diabetes controls my life
4. Feeling that I will end up with serious long term complications, no matter what I
do
5. Feeling overwhelmed by the demands of living with diabetes
6. Not feeling motivated to keep up my diabetes self-management
7. Feeling like I can’t control my eating
8. Feeling constantly deprived around food and eating
9. Feeling like I am not sticking closely enough to a good meal plan
10. Feeling like I am not getting enough daily movement/activity
11. Feeling I am not checking my blood sugars enough
12. Feeling like there is no one in my life with whom I can talk openly about my
feeling of diabetes
13. Feeling alone with diabetes
Section 2: Mindful Eating
Read the following statements. Select the column that most closely describes how you eat and make food choices.
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Rows
Always (1)
Often (2)
Sometimes (3)
Rarely (4)
Never (5)
I don't know (6)
14. I eat when I am hungry instead of eating in response to emotional and
environmental triggers.
15. I eat my meals and snacks away from distractions such as TV or computer
16. I take the time to enjoy taste, texture and mouth feel of food I am eating
17. I trust my body to tell me how much to eat (i.e. I do not feel the need to
measure/weigh etc.)
18. I trust my body to tell me what to eat (i.e. I do not feel the need to consult a list
of good/bad food, diet etc.)
19. I trust my body to tell me when to eat (instead of by the clock)
20. I give myself permission to eat the food I want without feelings of guilt
21. I stop eating when I feel full (or overstuffed)
Section 3: Mindfulness
Below is a collection of statements about your everyday experiences. Using the 1-6 scale, indicate how frequently or infrequently you currently have each experience. Please answer according to what really reflects your experiences rather than what you think your experiences should be. Please treat each experience separately from every other item.
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Almost never(1)
Very infrequently (2)
Somewhat infrequently (3)
Somewhat frequently (4)
Very frequently (5)
Almost always (6)
22. I tend not to notice feelings of physical tension or discomfort until they really
grab my attention
23. It seems as though I am running on "automatic", without much awareness of
what i am doing
24. I find myself preoccupied with future and past
25. I find myself snacking without realizing I’m eating
Section 4: Weight Control Beliefs
Please read each statement and decide how well each one describes your beliefs.
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Rows
Not true(1)
Slightly true (2)
Moderately true (3)
Very true (4)
26. I focus on healthy living rather than on controlling my weight
27. I try to accept the weight that is natural for me and focus on living a healthy lifestyle
28. I am comfortable letting my weight fluctuate naturally
29. It is important to me that I accept the weight that comes with living a healthy
lifestyle
30. I’d rather live healthily and accept that we all come in different shapes and sizes
31. If I am living a healthy lifestyle, my body is likely at the weight I am meant to be
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