Personal Reflection Name * First Name Last Name Please answer the following questions: * Do you currently have a mealtime structure or routine in place? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you usually look forward to meals/snacks? Strongly Disagree Disagree Neutral Agree Strongly Agree Would you say you have developed a meal habit? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you provide yourself with food you enjoy? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you know how to plan satisfying meals and snacks? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you generally tune into your body and enjoy your food during meals/snacks? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you usually tune in when your body tells you you’re hungry? Strongly Disagree Disagree Neutral Agree Strongly Agree Have you found your comfortable “stopping place” with eating? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you depend on your internal regulators of food intake to guide you in how much to eat? Strongly Disagree Disagree Neutral Agree Strongly Agree Can you put unfamiliar, challenging, and “nutritious” food on the table without strong arming yourself or anyone else to eat it? Strongly Disagree Disagree Neutral Agree Strongly Agree Are you generally relaxed about eating? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you feel comfortable about enjoying food? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you feel you eat a well-balanced, nutritious diet? Strongly Disagree Disagree Neutral Agree Strongly Agree If not, what do you think is the most significant barrier? (e.g. time, cooking skills, budget constraints, etc.) * If you could set one specific goal today, no matter how small, what would it be and why? * Thank you!
