This handout, Nutritional Symptoms Questionnaire (page 164), from DBT Holistic Skills Workbook for Teens, asks students to check in with the amount of lifestyle symptoms they may be experiencing that could be related to their nutrition. 

These twenty YES/NO questions inquire as to whether the student is experiencing bloating, acne, and constipation. These and other symptoms often have a lot to do with food intake, so it is a powerful way for teens to check in with their nutrition habits.

This questionnaire is meant to be taken just once in a while, depending on the nutritional changes being made.

Here is an example plan: 

1. Once per month to start after several weeks of any particular nutritional change. 

2. Later, it can be taken once each quarter and eventually once per year, or just in relation to a significant nutritional change.

[For comparison, the Meal Reaction Questionnaire Handout (Page 163) asked questions to help teens identify whether or not their meal helped them to feel satisfied, emotionally lifted, and mentally clear (or not). That handout was to be taken in the 30-90 minutes after finishing a meal.]