ARFID Questionnaire Form

Specialist Hypnotherapy
(Robertson Health Trust)

(Please complete and press SUBMIT at the end of the form)

CLIENT DETAILS

Client Name

First Name

Last Name

Client Date of Birth

YYYY

Parent/Guardian Name (if applicable)

First Name

Last Name

Address: (State & Country only)

1. Provide details of when the ARFID symptons were first noticed (age) and any relevant issues that presented around that time

(ie. Gastro, tongue tie, colic, reflux, allergies, vomiting, choking, vaccination reactions, constipation, tonsils/adenoids removed, medical trauma, emotional issues, family issues, moving school/kinder/creche/house/etc.),

2. Provide details of any issues you are aware of in conjunction with ARFID

(ie. Sensory issues (SPD), Autism (ASD), ADHD, Hypermobility, Emetophobia, OCD, PDA, Interoceptive Challenges, GAD (Anxiety), etc.)

3. Provide indicative foods/meals eaten at these times

Breakfast

Lunch

Dinner

Snacks and other foods

4. Provide details of participation in any current (or past) activities

(i.e. Sports, music, dance, gaming, art, clubs, etc.)

5. How interested or motivated are you to change how you feel around new food?

It's time! Let's do it.

I want to, but I'm a bit nervous.

Slightly... but as long as I don't have to put in any effort

Not really... I'm only here because Mum/Dad made me attend

6. Please note any additional information you believe is relevant or useful

(Hospital stays, other ED challenges, traumatic life events, etc.)

Confidential ARFID Questionnaire Form

Robertson Health Trust (ARFID Therapy & Specialist Hypnotherapy)

ARFID Questionnaire Form

Specialist Hypnotherapy(Robertson Health Trust)

Specialist Hypnotherapy
(Robertson Health Trust)