Emotional Eating Self-Assessment
Reflect on your eating habits and emotions to better understand your relationship with food.
Full Name
First Name
Last Name
Age
How often do you eat in response to emotions (such as stress, sadness, boredom, or anxiety)?
*
Never
Rarely
Sometimes
Often
Always
Which emotions most commonly trigger your eating?
*
Stress
Sadness
Loneliness
Boredom
Happiness
Anxiety
Other
Please rate how strongly you agree with the following statements about your eating habits.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I eat more when I am feeling stressed.
1
2
3
4
5
I crave specific foods when I am emotional.
6
7
8
9
10
I use food as a reward for myself.
11
12
13
14
15
I feel out of control when eating during emotional times.
16
17
18
19
20
After eating for emotional reasons, I feel guilty or regretful.
21
22
23
24
25
How often do you eat when you are not physically hungry?
*
Never
Rarely
Sometimes
Often
Always
How would you rate your awareness of your hunger and fullness cues?
*
1
2
3
4
5
When experiencing emotional eating, which types of foods do you usually crave?
*
Sweet foods (e.g. chocolate, candy, pastries)
Salty snacks (e.g. chips, pretzels)
Comfort foods (e.g. pasta, bread, pizza)
Healthy foods (e.g. fruits, vegetables)
Other
How do you typically feel after eating in response to emotions?
*
Satisfied and content
Guilty or regretful
Still craving more food
No change in mood
Other
Have you ever tried strategies to manage emotional eating?
*
Yes, and they helped
Yes, but they did not help
No, I have not tried any strategies
Please share any additional thoughts or experiences about your emotional eating habits.
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