Appetite & Nutrition Screening (Long-Term Cannabis Use)

Screening & symptom-tracking tool for appetite loss patterns that may be associated with ongoing cannabis use, reduced intake, or withdrawal.

Double Board Certified Counseling Services, Inc. • Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ADHD-CCSP, C-DBT, CCTP

Provider
Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ADHD-CCSP, C-DBT, CCTP
Double Board Certified Counseling Services, Inc.

Date

Auto-filled. Adjust if documenting a different session date.

Client Name

Context Select… Intake / Initial screening Session follow-up Medication / medical coordination Recovery / reduction plan monitoring

Timeframe rated Select… Past 7 days Past 2 weeks Past 30 days

Unintentional weight change (approx.) Select… No notable change Loss: < 5 lb Loss: 5–10 lb Loss: 11–20 lb Loss: > 20 lb Unsure / not tracking

This is a screen — consider objective weight/BMI trends when available.

Cannabis Use Snapshot

Frequency Select… Daily 4–6 days/week 1–3 days/week < 1 day/week Not currently using

Recent change Select… No change Increased Decreased Stopped within last 14 days Stopped > 14 days ago

Appetite can shift during reduction/withdrawal; track over time.

Primary form Select… Flower / smoking Vape Edibles Concentrates Mixed

Rating Scale

For each item, choose: 0 = Not at all, 1 = Mild, 2 = Moderate, 3 = Severe. Items focus on appetite loss patterns often seen with chronic use, morning appetite suppression, “only hungry when using,” nausea/avoidance, and withdrawal-related symptoms.

Item	Rating (0–3)	Notes (optional)
1. Low appetite or reduced interest in food (overall).	01 23
2. Appetite is significantly worse in the morning (breakfast difficult).	0123
3. Appetite improves mainly after cannabis use (“only hungry when I use”).	0123
4. Nausea, stomach discomfort, or food aversion reduces intake.	0123
5. Eating feels like a “task,” I delay meals, or forget to eat.	0123
6. When reducing/stopping cannabis, appetite drops noticeably.	0123
7. Sleep disruption, irritability, anxiety, or restlessness accompany appetite change.	0123
8. Reduced eating is impacting energy, mood, work, or daily functioning.	0123
9. I have episodes of vomiting, severe nausea, or relief with hot showers/baths.	01 23
10. I avoid food due to body image, fear of weight gain, or other eating concerns.	01 23

Red-Flag Check (Yes/No)

Rapid weight loss, fainting, dehydration, or inability to keep fluids down Blood in vomit/stool, severe abdominal pain, chest pain, or persistent fever Pregnant/postpartum or significant medical condition affecting appetite

Concern for eating disorder behaviors (restriction, purging, laxatives, etc.) Suicidal thoughts, self-harm, or acute psychiatric instability Possible cannabis hyperemesis pattern (vomiting cycles + relief with hot showers)

If any are checked, consider medical evaluation/coordination and higher level of care as clinically indicated.

Total Symptom Score: 0 (range depends on endorsements; weighted items 9–10 count double)

Severity Band: --

Complete items and click “Score”.

Clinical Attention Flag: One or more red-flag items were selected. Consider medical evaluation/coordination, risk assessment, and/or higher level of care as appropriate.

Clinical summary (brief)

Plan / recommendations (brief)

Score Reset Print

Interpretation tips: Appetite changes can have multiple causes (stress, depression/anxiety, ADHD-related meal-skipping, GI issues, medications, medical conditions). This tool supports tracking patterns over time and guiding clinical decision-making.

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