| | Yes | No |
| 1. | Do you keep lots of junk food in your house? | | |
| 2. | Do you store food in your house in plain sight? | | |
| 3. | Do you have candy-filled dishes and/or bowls of nuts in your house? | | |
| 4. | Do you store food in rooms of your house other than your kitchen? | | |
| 5. | Does your desk drawer look like a convenience store? | | |
| 6. | Do you keep food stashed in your glove compartment or purse? | | |
| 7. | Do you routinely prepare family-style meals served on large platters? | | |
| 8. | Do you choose restaurants with buffets or family-size meals? | | |
| 9. | Do you have numerous diet books in your house? | | |
| 10. | Do you eat by the clock? | | |
| 11. | Does your daily route take you by vending machines, restaurants, bakeries, or other eateries? | | |
| 12. | Do you shop without a grocery list? | | |
| 13. | Does the presence of specific people trigger you to eat? | | |
| 14. | Do you prepare snacks for your kids or spouse? | | |
| 15. | Are you the only one who cleans up the kitchen after a meal? | | |
| 16. | Do you keep fattening foods easily accessible? | | |
| 17. | Do you buy fattening foods in large packages? | | |
| 18. | Do you buy extra-large bags of easy-to-eat processed foods (such as chips, candy, or cookies)? | | |
| 19. | Are you reluctant to throw out fattening leftovers? | | |
| 20. | Do you plan what you will eat prior to going to a restaurant? | | |