PARDI-AR-Q

The following questions are about your eating – some ask about how things currently are, others ask about things over the past month or the past 3 months. Please select the choices that apply to you, or enter the information requested.

Please read each question carefully. Please answer all the questions. Thank you.

Please enter today's date.

Please enter your date of birth.

Are you male, female or other?

What is your current height (ft and in)?

What is your current weight (lbs)?

Do you think you have a problem with eating, involving avoidance or restriction of foods or your eating overall?

Yes No

Have other people (for example, doctors, family members, significant others) said that you have a problem with eating, involving avoidance or restriction of foods or your eating overall?

Yes No

Have your eating habits led to difficulty maintaining a sufficient weight or, if you are still growing, difficulty gaining enough weight to keep pace with your growth?

Yes No

Have your eating habits led to you losing weight (in other words, if you have lost weight, this is because of avoidance or restriction and not because of a medical illness, or other reason)?

Yes No

If you answered yes to the question above, how much weight (in lbs) have you lost in the past 3 months?

Have others (for example, doctors, family members) been concerned about your weight loss, or been concerned that you are having difficulty gaining enough weight to grow, or having difficulty maintaining your weight due to your eating habits?

Yes No

Have others (for example, doctors, family members) been concerned that you are not growing taller as you should due to your eating habits?

Yes No I have finished growing

Have you ever been told by any health professional that due to your eating habits you were not growing as expected, or that your height was less than it should be?

Yes No

Over the past month, has any health professional said that you have a nutritional deficiency due to your eating habits (for example, low iron, low vitamin B12, low vitamin C)?

Yes No

Over the past month, has a healthcare professional prescribed special supplements (for example, pills, capsules, powders, or drinks containing vitamins and/or minerals and other micronutrients) specifically to help with your nutrition?

Yes No

If you answered yes to the question above, what have you been prescribed and how much do you take each day?

Over the past month, has a healthcare professional prescribed special supplements (for example, high-calorie drinks or ‘shots’, or dessert-style high-calorie supplements) specifically to help you maintain or gain weight?

Yes No

If you answered yes to the question above, what have you been prescribed and how much do you take each day?

Are you currently receiving any tube feeding (receiving food or fluid via a tube in your nose or into your stomach)?

Yes No

If you answered yes to the question above, what is the name of the food or fluid product you take via the tube and how much do you take each day?

Does your eating cause you difficulties in daily functioning - that is, in how you are able to go about things each day? This might be at school/college/work or when you are at home.

Yes No

Does your eating cause you difficulties in interactions with other people (for example, disagreements or arguments with parents, siblings, significant others, co-workers), or difficulty making or sustaining friendships or other close relationships?

Please choose a number below how difficult interactions with other people are for you because of your eating, ranging from 0 (= no difficulty) to 6 (= extremely difficult)

0 (No Difficulty) 1 2 3 4 5 6 (Extremely Difficult)

Does your eating cause you difficulties in social situations, for example does it make it difficult for you to go out with friends, eat at school/college/work, or stay away from home?

Please choose a number below how difficult social situations are for you because of your eating, ranging from 0 (= no difficulty) to 6 (= extreme difficulties/try to avoid all social situations)

0 (No Difficulty) 1 2 3 4 5 6 (Extreme Difficulties)

Over the past month, have you been particularly sensitive to variation in taste (for example, noticing slight differences in the taste of foods), which has put you off eating any foods or trying any new foods?

Please choose a number below how much sensitivity to taste has affected your eating, ranging from 0 (= no negative effect/no particular sensitivity to taste) to 6 (= extremely negative effect, for example, leading to refusal to eat many foods, sticking only to a limited number of preferred foods, or extreme caution when eating )

0 (No Negative Effect) 1 2 3 4 5 6 (Extremely Negative Effect)

Over the past month have you been particularly sensitive to the texture or consistency of food, which has put you off eating any foods or trying any new foods (for example, do you stick to foods of a certain texture only or have you had difficulty eating foods that have different textures mixed together such as pasta with sauce or sandwiches)?

Please choose a number below how much sensitivity to texture or consistency has affected your eating, ranging from 0 (= no negative effect/no particular sensitivity) to 6 (=extremely negative effect, for example, leading to refusal to eat many foods, sticking only to a limited number of preferred foods, or extreme caution when eating)

0 (No Negative Effect) 1 2 3 4 5 6 (Extremely Negative Effect)

Over the past month, have you been particularly sensitive to the appearance of food, which has put you off eating any foods or trying any new foods (for example, if food does not look “right”, such as burnt ends of chips/fries, broken biscuits/cookies, or being the “wrong” color)?

Please choose a number below how much sensitivity to the appearance of food has affected your eating, ranging from 0 (= no negative effect/no particular sensitivity) to 6 (=extremely negative effect, for example, leading to refusal to eat many foods, sticking only to a limited number of preferred foods, or extreme caution when eating)

0 (No Negative Effect) 1 2 3 4 5 6 (Extremely Negative Effect)

Over the past month, how often have you forgotten to eat or found it difficult to make time to eat?

Please choose a number below how often you have forgotten to eat or found it difficult to make time to eat, ranging from 0 (= never) to 6 (=always)