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Mood-Diet Questionnaire
Please circle the points given to each description if it fits how you have felt for the current month or longer at least half of the time. Please total all sections.
4 Sensitivity to emotional (or physical) pain; cry easily 4 Eat as a reward or for pleasure, comfort, or numbness 4 Difficulty getting to sleep or staying asleep 3 Difficulty with focus, attention deficits 4 Inability to relax after tension, stress 4 More mood and eating problems in winter or at end of the day 4 Increased cravings for and focus on food after dieting 4 Regain weight after dieting, more than was lost 3 Increased moodiness, irritability, anxiety, or depression 3 Usually eat less than 2,100 calories per day 3 Eat mostly low-fat carbohydrates (bagels, pasta, frozen yogurt, and others) 2 Take Prozac or similar serotonin-boosting drugs BLOSSOM GREEN WELLNESS COACHING / BLOSSOMGREEN.COM 4 Have become bulimic, anorectic, or over-exerciser 4 Crave a lift from sweets or alcohol, but later experience a drop in energy and mood after ingesting them 3 Dizzy, weak, or headachy, especially if meals are delayed 4 Family history of diabetes, hypoglycemia, or alcoholism 3 Nervous, jittery, irritable on and off throughout the day; calmer after meals 5 Sores on legs that take a long time to heal 4 Easily chilled, especially hands and feet 4 Other family members have thyroid problems 4 Can gain weight easily without overeating; hard to lose excess weight 3 Have to force yourself to do even moderate exercise 4 Find it hard to get going in the morning 4 Weight gain began near the start of menses, a pregnancy, or menopause 3 Use of food, caffeine, tobacco, and/or other stimulants to get going BLOSSOM GREEN WELLNESS COACHING / BLOSSOMGREEN.COM 3 Crave milk, ice cream, yogurt, cheese, or doughy foods (pasta, bread, cookies,etc) and eat them frequently 4 Respiratory problems, such as asthma, postnasal drip, congestion 3 Low energy or drowsiness, especially after meals 4 Allergic to milk products or other common foods 3 Under-eat or often prefer beverages to solid food 3 Avoid food or throw up food because bloating after eating makes you feel fat or tired 4 Premenstrual or menopausal food cravings 3 Experienced a miscarriage, an abortion, or infertility 4 Use(d) birth control pills or other hormone medication 3 Uncomfortable periods- cramps, lengthy or heavy bleeding, or sore breasts 4 Peri- or post-menopausal discomfort (hot flashes, sweats, insomnia, or mental dullness) BLOSSOM GREEN WELLNESS COACHING / BLOSSOMGREEN.COM 4 Used antibiotics extensively (at any time in life) 4 Used cortisone or birth control pills for more than one year 4 Have chronic fungus on nails or skin or athlete’s foot 3 Recurring sinus or ear infections as an adult or child 3 Stool unusual in color, shape, or consistency 4 Crave chips, cheese, and other rich foods more than, or in addition to sweets and starches 4 Have ancestry that includes Irish, Scottish, Welsh, Scandinavian, or coastal Native American 4 Feel heavy, uncomfortable, and “clogged up” after eating fatty foods 4 History of hepatitis or other liver or gallbladder problems 2 Have lost your gallbladder or had gallstones BLOSSOM GREEN WELLNESS COACHING / BLOSSOMGREEN.COM BLOSSOM GREEN WELLNESS COACHING / BLOSSOMGREEN.COM

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