The Bingeing Breakthrough
Please complete this form for me to give you some personalised feedback on your eating & lifestyle habits. The more information you provide, the better! 

After submitting the form, you'll receive a video within 2 working day. If you have any questions, please reach out to me on: lara@drlarazib.com
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Email *
What is your name? *
Today's date *
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Please tell me a little bit about your relationship with food currently. *
What do you generally tend to eat on a "good" day? Please include meals, snacks, drinks and the time of day you eat these foods. *
What do you generally tend to eat on a "bad" day? Please include meals, snacks, drinks and the time of day you eat these foods. *
How hungry are you typically before you eat [if 1 = not hungry at all and 10 = hunger off the charts]? Please expand if this is different on different days/occasions.  *
How quickly do you typically eat [if 1 = not quickly at all and 10 = as fast as possible]? Please expand if this is different on different days/occasions. 
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Are there any specific foods, situations or emotions that trigger a binge? Please give as much information as possible here. *
How often do you experience binge-eating episodes? *
What diets or eating plans have you tried in the past? (Briefly describe your experience and outcomes) *
What strategies or methods have you used to control or stop binge eating?
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What do you most want to change about your relationship with food? *
Do you have any medical conditions or take any medications that impact your eating habits?
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Is there anything else you'd like to share with me? *
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