Name *

Contact Number *

Email Address *

Actual date of Birth *

Weight management treatments, surgery, therapy, and other modifications, exercises made in the past and present *

1. I deliberately take small helpings to control my weight. *

2. I start to eat when I feel anxious *

3. Sometimes when I start eating, I just can’t seem to stop. *

4. When I feel sad, I often eat too much. *

5. I don’t eat some foods because they make me fat *

6. Being with someone who is eating, often makes me want to also eat. *

7. When I feel tense or ‘‘wound up’’, I often feel I need to eat. *

8. I often get so hungry that my stomach feels like a bottomless pit *

9. I’m always so hungry that it’s hard for me to stop eating before finishing all of the food on my plate *

10. When I feel lonely, I console myself by eating *

11. I consciously hold back on how much I eat at meals to keep from gaining weight. *

12. When I smell a sizzling steak or see a juicy piece of meat, I find it very difficult to keep from eating - even if I’ve just finished a meal *

13. I’m always hungry enough to eat at any time. *

14. If I feel nervous, I try to calm down by eating. *

15. When I see something that looks very delicious, I often get so hungry that I have to eat right away. *

16. When I feel depressed, I want to eat. *

17. How often do you avoid ‘‘stocking up’’ on tempting foods? *

18. How likely are you to make an effort to eat less than you want? *

19. Do you go on eating binges even though you’re not hungry? *

20. How often do you feel hungry? *

Three-Factor Eating Questionnaire-R21: Uncontrolled Eating Domain - Out of 36

Three-Factor Eating Questionnaire-R21: Cognitive Restraint Domain - Out of 24

Three-Factor Eating Questionnaire-R21: Emotional Eating Domain - Out of 24

Eating Pattern

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