ARFID Questionnaire

Test for Avoidant/Restrictive Food Intake Disorder

Please complete the following questionnaire and we will contact you to discuss your responses:

Do you consume a limited food variety?*

Yes

Do you often gag when eating certain foods?*

Yes

Do you go through phases of eating the same food repeatedly and exclusively for a while, to then get tired of it and stop eating it all together?*

Yes

Is mealtime stressful because of foods that are presented at the table?*

Yes

Do you struggle with eating certain foods because of their texture?*

Yes

Do you feel anxious about trying foods that you haven’t had before because you worry you may not like them?*

Yes

Do you avoid social settings where food is present for fear there may not be something there you like to eat?*

Yes

Would you rather go hungry than eat food you don't like?*

Yes

Do you avoid eating foods if you don't like how they look?*

Yes

Do you lose interest in food eating generally?*

Yes

Do friends and family call you a “picky eater”?*

Yes

Do you only eat a particular brand of certain foods?*

Yes

First name*

Last name*

Email*

Please confirm that you agree for us to contact you:

I agree

We will contact you using the email address you have provided above (please check your Junk/Spam folder for an email from enquiries@Flourishtherapyclinic.co.uk).

If you prefer us to ring you, please provide your phone Number

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Registered Address: Ribblesdale House, 14 Ribblesdale Place, Preston PR1 3NA

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Call us 01772 915735

Call us 01772 915735

ARFID Questionnaire

​Test for Avoidant/Restrictive Food Intake Disorder

Test for Avoidant/Restrictive Food Intake Disorder