Food Freedom Experience
Clarity Questionnaire
Personal Information
Name:
(Nickname):
Address:
Home Tel:
Email:
Cell:
Date of Birth:
Significant Other?:
How Long?
Children (names and ages)
Occupation:
How Long?
*All personal information is confidential
Please answer the following questions:
What are your 3 biggest challenges right now around food and your body?
How is this impacting your life?
Food Freedom Experience – Pre Game Assignments
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How long has this been an issue for you?
What have you tried in the past to deal with it?
What do you want instead?
What is your earliest memory about food/eating?
Do you consider food “friend” or “foe”?
Who are you as an eater (how would you define yourself)?
Please tell me 3 core beliefs that determine how you think, feel and act around
eating.
Who would you like to be as an eater?
What’s preventing you from experiencing that right now?
Please tell me three habits, patterns or excuses that STOP your forward movement.
How do you feel about your body?
When do you first remember developing a concern around your body?
How often do you weigh yourself?
What forms of movement/exercise do you engage in? How often?
© 2013 Michelle Leath, All Rights Reserved
www.unlockyourpossibility.com
Food Freedom Experience – Pre Game Assignments
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Are you a fast eater, a slow eater or a moderate eater?
Describe your typical day in terms of what you normally eat and at what time of
day. (If you travel frequently or have a varied schedule, please include all scenarios)
Breakfast:
Lunch:
Snacks:
Dinner:
After Dinner:
When do you typically eat the most (biggest meal of the day)?
The least
(smallest meal of the day)?
Do you experience or have you been diagnosed with any digestive problems (GERD,
IBS, etc.)? If so, please describe.
Tell me your biggest food/weight/body fear.
What’s in you that’s dying to get out?
What’s one breakthrough you are committed to creating during our time together?
© 2013 Michelle Leath, All Rights Reserved
www.unlockyourpossibility.com
Food Freedom Experience – Pre Game Assignments
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Where’s Your Eating Stress?
For each of the following questions, answer how frequently you experience each scenario – with 1
being “never” and 5 being “all the time!”
I eat standing up
1
2
3
4
5
I eat working at my computer/desk
1
2
3
4
5
I hurry through meals to get back to work
1
2
3
4
5
I feel confused about what I should or shouldn’t eat
1
2
3
4
5
I feel guilty about what I am eating
1
2
3
4
5
I eat in my car/ “on the go”
1
2
3
4
5
I eat in front of the TV
1
2
3
4
5
I eat while I am Facebooking
1
2
3
4
5
I see food as an adversary/enemy
1
2
3
4
5
I believe eating food = fat on my body
1
2
3
4
5
I grab whatever is available
1
2
3
4
5
I’m too busy to plan and prepare meals
1
2
3
4
5
I have cravings for sweets/refined carbs
1
2
3
4
5
I have cravings for salty/crunchy things
1
2
3
4
5
My digestive system is upset/irritable
1
2
3
4
5
I tend to eat more when I’m anxious/sad/upset
1
2
3
4
5
The people I eat with stress me out
1
2
3
4
5
© 2013 Michelle Leath, All Rights Reserved
www.unlockyourpossibility.com
Food Freedom Experience – Pre Game Assignments
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I have negative thoughts about my body
1
2
3
4
5
I feel like I can’t be myself
1
2
3
4
5
I experience work stress
1
2
3
4
5
I have a hard time sitting still/relaxing
1
2
3
4
5
I skip breakfast
1
2
3
4
5
I eat a big dinner
1
2
3
4
5
I’m very particular about what I eat
1
2
3
4
5
I find myself snacking after dinner
1
2
3
4
5
I work out to make up for what I’ve eaten
1
2
3
4
5
I don’t have time to sit down for meals
1
2
3
4
5
What Really Fills You Up?
Assignment:
Do a little brainstorming and write down everything you can think of that gives you
pleasure in each of the 3 categories below. What really makes your taste buds sing?
What makes your heart sing? What leaves you feeling fulfilled and nourished? What
is just straight-up hedonistic enjoyment?
Healthy Food Pleasures
These are the things you’ve learned or intuitively know are healthy for you, and have
the added bonus of being scrumptious to you. This might include your favorite
© 2013 Michelle Leath, All Rights Reserved
www.unlockyourpossibility.com
Food Freedom Experience – Pre Game Assignments
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fruits, a delicious piece of fish, a favorite salad, a glass of red wine, perhaps a
favorite restaurant or meal, or a certain spice or herb – anything that you really get
pleasure from. No matter how healthy it is, if it doesn’t truly give you pleasure do
not include it!
Forbidden Food Pleasures
These are the things you really enjoy but limit or forbid yourself because you believe
that they are unhealthy, “fattening” or otherwise not OK to eat. Include everything
that turns you on, no matter how unhealthy you or anyone else believes the foods
to be. Be sure to include details that paint the full pleasure picture (specific meals,
brands, etc.). Be aware of any foods you are tempted to include because they are
forbidden – do they really give you pleasure?
Personal Pleasures
Now list everything else (non-food) that gives you pleasure – people, places,
experiences, activities, a favorite object or piece of furniture in your home,
entertainment, sensual or sexual delights. For me this includes comedy movies, my
leopard flannel sheets, getting a massage at a luxurious spa, Hawaii, a bubble bath,
freesias on my desk, a hand-blown glass candle holder I have…. Anything goes, as
long as it delights you!
© 2013 Michelle Leath, All Rights Reserved
www.unlockyourpossibility.com