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DEPARTMENT OF PSYCHIATRY
Center for Weight and Eating Disorders


NIGHT EATING SYNDROME QUESTIONNAIRE

Please answer ALL of the following questions:

Name:
E-mail Address: (required)
Phone number:
City:
State/Province
Country:
Gender: Male
Female
Age:
Age when weight first became a problem:
Height:
Current Weight: lbs.
Heaviest Weight: lbs.
1. How hungry are you usually in the morning?
Not at all A little Somewhat Moderately Very
 
2. When do you usually eat for the first time?
Before 9 a.m. 9:01 a.m. to 12:00 p.m. 12:01 p.m. to 3:00 p.m. 3:01 p.m. to 6:00 p.m. After 6:01 p.m.
 
3. Do you have cravings or urges to eat snacks after supper but before bedtime?
Not at all A little Somewhat Very much so Extremely so
 
4. How much control do you have over your eating between supper and bedtime?
None at all A little Somewhat Very much so Extremely so
 
5. How much of you daily food intake do you consume after suppertime?
0%
     (none) 		1 - 25%
  (up to a quarter) 		25 - 50%
   (about half) 		50 - 75%
  (more than half) 		75 - 100%
     (all)
 
6. Are you currently feeling blue or down in the dumps?
Not at all A little Somewhat Very much so Extremely
 
7. When you are feeling blue, is your mood lower in the:
Early Morning Late Morning Afternoon Early Evening Late Evening/Nighttime
Click here if you mood does not change during the day.
 
8. How often do you have trouble getting to sleep?
Never Sometimes About half the time Usually Always
 
9. Other than only to use the bathroom, how often do you get up at least once in the middle of the night?
None at all Less than onces a week About once a week More than once a week Every night
 
10. Do you have cravings or urges to eat snacks when you wake up at night?
Not at all A little Somewhat Very much so Extremely so
Click here if you do not wake up at night.
 
11. Do you need to eat in order to get back to sleep when you awake at night?
Not at all A little Somewhat Very much so Extremely so
Click here if you do not wake up at night.
 
12. When you get up in the middle of the night, how often do you snack?
Never Sometimes About half the time Usually Always
Click here if you do not wake up at night.
 
13. When you snack in the middle of the night, how aware are you of your eating?
Not at all A little Somewhat Very much so Completely
Click here if you do not snack during the night.
 
14. How much control do you have over your night-time eating?
None at all A little Some Very much Complete
Click here if you do not snack during the night.
 
15. How long have your current difficulties with night eating been going on?

Years

(fill in "0" if less than one year)

Months
16. Does anyone else in your family have problems with night eating, either now or in the past?
 Yes   No

If Yes, Please Describe:
Comments/Questions:
I agree to the TERMS OF USE (click to read.) NOTE: This must be checked in order to submit the form.

 

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