Short ARFID Screen – Self

This questionnaire is intended to help individuals ages 14 and older identify whether their eating habits are a flag for the possibility that they are experiencing avoidant/restrictive food intake disorder (ARFID). For each question, fill in the checkbox in the column labelled with the response that is most applicable to you.

Full Name *

Email *

Questions

1. Do you have difficulties with eating – involving avoidance or restriction of certain foods or of overall amount eaten – that are NOT explained by a diagnosed medical condition? *

Yes, definitely

To some extent

No, not at all

Unsure

2. Are your eating habits related to you thinking that you are too big or too heavy? *

Yes, definitely

To some extent

No, not at all

Unsure

3. Over the past 3 months, has your eating led to difficulty maintaining a healthy weight, OR if you are still growing, difficulty gaining enough weight to grow as expected? *

Yes, definitely

To some extent

No, not at all

Unsure

4. Do you have any nutritional deficiencies or inadequacies as a result of limited eating (e.g. low iron, low vitamin B12, low vitamin C, etc.)? *

Yes, definitely

To some extent

No, not at all

Unsure

5. Do you depend on tube feeding or nutritional supplements to maintain your nutrition, weight or growth (i.e. without these you would have nutritional deficiencies or lose weight)? *

Yes, definitely

To some extent

No, not at all

Unsure

6. Does your eating have a negative effect on your day to day life or your ability to participate in a full range of age-appropriate activities? *

Yes, definitely

To some extent

No, not at all

Unsure

7. Does your eating have a negative effect on your family/partner relationships or other aspects of your family life (e.g. going out together, on holiday, etc.)? *

Yes, definitely

To some extent

No, not at all

Unsure

Please make sure you click SUBMIT to finalize your responses.

Thank you!