Nutritional Audit - The Couple Challenge

This is to help us create your implementation plan.

Name

First Last

Rate these from 1-10

(1= this doesn’t apply to me, 5= I kinda struggle with this, 10= I struggle with this, please help me!!)

1. During Meals

I have a hard time recognizing my hunger and satiety cues:(Required)

Please enter a number less than or equal to 10.

I eat too much food:(Required)

Please enter a number less than or equal to 10.

My stomach always hurt after I eat:(Required)

Please enter a number less than or equal to 10.

I don’t eat enough food:(Required)

Please enter a number less than or equal to 10.

I don’t know how much to eat :(Required)

Please enter a number less than or equal to 10.

I tend to overeat because:

I don’t know when to stop:(Required)

Please enter a number less than or equal to 10.

I keep eating even if I’m full because I enjoy the taste/flavor:(Required)

Please enter a number less than or equal to 10.

I don’t know how much to eat:(Required)

Please enter a number less than or equal to 10.

It's a habit:(Required)

Please enter a number less than or equal to 10.

I always get seconds:(Required)

Please enter a number less than or equal to 10.

2. Between Meals

I snack a lot:(Required)

Please enter a number less than or equal to 10.

I eat when I'm tired:(Required)

Please enter a number less than or equal to 10.

I eat when I'm stressed:(Required)

Please enter a number less than or equal to 10.

I snack a lot because I crave food:(Required)

Please enter a number less than or equal to 10.

I snack between meals because I get hungry:(Required)

Please enter a number less than or equal to 10.

I snack when I watch TV:(Required)

Please enter a number less than or equal to 10.

I snack late at night:(Required)

Please enter a number less than or equal to 10.

3. Others

Answer YES or NO, or how much/how many (when applicable)

I restrict on the foods I love so I end up binging:

YES

Other

I don’t have time to cook:

YES

Other

I enjoy cooking:

YES

Other

I have a good relationship with food:

YES

Other

I know how to eat healthy:

YES

Other

I know how to eat healthy, I just don’t do it:

YES

Other

I order food ___ times a week

I drink alcohol ___ times a week

I find it difficult to resist food:

YES

Other

I have a “go hard or go home” mentality:

YES

Other

I have a perfectionist mentality:

YES

Other

I’m scared of failing/making mistakes:

YES

Other

I have a hard time distinguishing hunger from cravings/emotional eating:

YES

Other

I sleep an average of ___ per night:

I feel tired most of the time:

YES

Other

In the past, I’ve eaten when I was tired:

YES

Other

In the past, I’ve had trouble with cravings:

YES

Other

In the past, I’ve eaten when I was stressed:

YES

Other

In the past, I’ve eaten when I had unwanted emotions/thoughts:

YES

Other

I snack __ times a day

4. Others

Is there anything else we need to know about your nutrition? Add notes if applicable.

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