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Personal Information
Medical Questions

Listed below are 6 medical conditions; please select the current status of each.

Do you keep a food journal/log?

Are you measuring your foods?

How many meal replacements do you have daily?

Do you drink liquids with meals?

Besides your supplements, do you drink any calorie containing liquids?

Does food get stuck?

Do you vomit at least weekly?

Aside from holiday feasts, have you ever eaten a large amount of food rapidly and felt this eating incident was excessive or out of control?

Have you ever purged (used laxatives, diuretics or induced vomiting) to control your weight?

Do you think you would benefit from seeing the Psychologist?

Please check any of the following ulcer triggers that you are using.

Please list all foods and beverages consumed in the past 24 hours: