Fill in this diary questionnaire as soon as possible after a slip:

Time: ________________

Were you physically hungry?    Yes ___                        No___

If you were, what did you crave specifically? _______________________________________________

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Did this food remind you of certain people or places that you like? (vacation, summer, childhood, etc)?

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How did you feel just before you slipped? ______________________________________________________

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Were you “emotionally” hungry?          Yes___             No___

If so, what would it have taken to satisfy you? _____________________________________________

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Food eaten: Quality: __________________________________________________________________

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Quantity: ___________________________________________________________________________

How did you eat the food:         fast___             hiding from others___               slowly___

with gusto___                without thinking___

Did the food satisfy you?          Yes___             No___

If not, why not? _______________________________________________________________________

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How did you feel after your slip? _________________________________________________________

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Did you have any other reason to feel this way at the time? ____________________________________

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