ARFID Questionnaire (Please complete and press SUBMIT at the end of the form) CLIENT DETAILS Client Name * First Name Last Name Client Date of Birth * MM DD YYYY Parent/Guardian Name (if applicable) First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country 1. Provide details of when the ARFID Symptoms 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, 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. Would you like to expierience some positive change inhow you think, feel, behave and react around food? Radio * Yes No 6. How initerested or motivated are you to change how you feel around new food? Radio * 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 7. 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) Thank you!Your ARFID Questionnaire has been submitted and we look forward to working with you at your appointment.Regards…Glenn (ARFID Therapy)