1. What time do you usually go to bed in the evening (turn out the lights in order to go to sleep)?	_______ pm
2. What time do you usually get out of bed in the morning?	_______ am
3. On most days, do you experience loss of appetite in the morning?	□ No □ Yes
4. How often do you typically eat breakfast (after your final morning awakening)?	____ times/week
5. What time do you usually have the first meal of the day?	_____ am/pm (please circle)
6. How much food do you generally eat after 7 p.m. as a percentage (%) from 0 –100? (Please be specific, for example, 15%)	(0–100) _______%
7. What time do you usually have your evening meal?	_______ pm
8. How much food do you generally eat after your evening meal as a percentage (%) from 0 –100? (Please be specific, for example, 15%)   8a. For how long have you been consuming at least this     much after your evening meal?	(0–100) _______% _____ Years ____ Months
9. On most days, do you have a strong urge to eat between dinner and sleep onset and/or during the night?	□ No □Yes
10. Do you have trouble falling asleep at night?   10a. If YES, how many times each week?	□ No □ Yes _____ times/week
11. Do you have trouble staying asleep at night?   11a. If YES, how many times each week?   11b. If YES, how many times each week do you get out   of bed during these awakenings?	□ No □ Yes ________ times/week ________ times/week
12. How many times each week do you awake from sleep during the night to use the bathroom?	________times/week □ none
13. Do you awake from sleep during the night and eat food? IF NO, SKIP TO QUESTION 14   13a. If yes, how many times per week?   13b. For how long have you been getting up at this     frequency to eat?   13c. Do you believe you need to eat in order to fall back     to sleep when you wake up at night?   13d. How aware are you of your eating during the     night?   13e. How often do you recall your eating during the     night the next day?	□ No □ Yes ________ times/week _____ Years ____Months □ No □ Yes □ not at all □ somewhat □extremely □ never □sometimes □ always
14. Would you consider yourself a night eater? IF NO, SKIP TO QUESTION 15 IF YES (please answer the following questions):   14a. IF YES, how upset are you about your night     eating?   14b. IF YES, how much has your eating at night     impaired your functioning and/or interfered with     your daily life?   14c. For how long have you been experiencing this     night eating behavior?	□ No □ Yes □ not at all □somewhat □ extremely □ not at all □ somewhat □ extremely □ less than 3 months □ 3–6 months □ 6–12 months □ more than 1 year
15. Do you have sleep apnea?	□ No □ Yes □ Don’t know
16. Do you work an evening or night shift?   16a. IF YES, is it:   16b. IF YES, for how long have you been working this     shift?	□ No □ Yes □ evening □ night □ rotating ____Years ____Months
17. Have you been feeling depressed or down nearly every day?	□ No □ Yes
18. In general, when you are feeling depressed or down, is your mood lower in the:	□ morning □ afternoon □ evening/nighttime □ Not applicable
19. Are you currently dieting to lose weight?   19a. IF YES, how much weight have you lost in the past 3     months?	□ No □Yes _________ lbs
20. What is your current height and weight (without clothing or shoes)?	_______Height (in) ______Weight (lbs)
21. Please take a moment to review your responses. Have you answered each question completely?	□ No □Yes