ARFID Quiz: Do I Have ARFID?

Who do you want to help?

First Name

Last Name

Email

Zip Code

Clients First Name

Clients Last Name

Client's Email Address

Client's Phone #

Format: (000) 000-0000.

Yes, I give Permission to reach out directly to my client

Clients DOB

Client's Zip Code

Level of care client is interested in

Level of care your client is interested in

How did you hear about us?

Healthcare Provider Name and Practice

Phone Number

Format: (000) 000-0000.

Have insurance? You can include those details here so we can review coverage with you.

Insurance Name

Subscriber ID

Group #

Client DOB

I am the Policy Holder?

I am the Policy Holder Value

Subscriber First Name

Subscriber Last Name

Subscriber DOB

Relationship to Policy holder

Insurance Card

IsAttachmentSelected

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utm_campaign

utm_content

utm_medium

utm_source

utm_term

GCLID

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ARFID quiz: do I have ARFID?

Do you avoid certain foods because of texture, smell, or appearance?

Are you fearful of choking, vomiting, or getting sick from food?

Do you eat a very limited range of “safe” foods?

Has your eating pattern caused weight loss or nutritional concerns?

Do social events involving food cause anxiety?

Do you skip meals because nothing feels “safe” to eat?

Did these eating challenges begin in childhood?

Do you struggle to try new foods?

Has your doctor expressed concern about your growth or nutrition?

Is your food avoidance unrelated to body image concerns?

Based on your answers, you may have ARFID

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Based on your answers, you may not have ARFID

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