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| Initial of First name: |
Age: |
| Email address: |
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| Education Completed: |
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| Marital Status: |
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| My occupation/profession is: |
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| Are you employed now?: |
yes no |
| I am (click all that apply): |
overeater
binge eater
bulimic
anorexic
other
if other, please describe:
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Are you afraid you will relapse after overeating?:
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yes no |
| Please select an option after each question (N=never; S=seldom; O=often; C=constantly) |
| a) Do you eat when you are not hungry? |
N S O C |
| b) Do you go on eating binges for no apparent reason? |
N S O C |
| c) Do you have feelings of guilt and remorse about food and dieting? |
N S O C |
| d) Do you give too much thought and time to food? |
N S O C |
| e) Do you look forward with pleasure to when you can eat alone? |
N S O C |
| f) Have you purposely starved yourself because you are afraid of being fat? |
N S O C |
| g) have you used laxatives to control your weight? |
N S O C |
| h) Have you exercised as a way to control your eating, weight? |
N S O C |
| i) Do you plan secret eating times? |
N S O C |
| j) Do you eat sensibly in front of others and make up for it alone? |
N S O C |
| k) Is your weight affecting the way you live your life? |
N S O C |
| l) Have you ever tried to diet, only to fall short of your goal? |
N S O C |
| m) Do you resent others telling you what and how to eat? |
N S O C |
| n) Do you crave certain foods? |
N S O C |
| o) Do you eat to escape your worries or troubles? |
N S O C |
| p) Does your food obsession make you or others unhappy? |
N S O C |
| My Height Is: |
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| Information about my weight: |
Present weight:
Minimum adult weight:
Maximum adult weight: |
| Does your weight fluctuate more than 10 pounds? |
yes no |
| What is the longest you have maintained a stable weight? |
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| Looking back, at what age do you first recall having problems with dieting, body image, weight? |
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For the following questions, please number from 1 to 5:
1 = rarely; 2 = sometimes; 3 = average; 4 = frequently; 5 = always |
| a) overwork, overdo activities |
1 2 3 4 5 |
| b) strong need for recognition, approval and reward |
1 2 3 4 5 |
| c) blame others when things go wrong |
1 2 3 4 5 |
| d) am frequently disappointed in friends, family |
1 2 3 4 5 |
| e) isolate from others |
1 2 3 4 5 |
| f) when things aren't exactly as I expect, I am upset |
1 2 3 4 5 |
| g) restless |
1 2 3 4 5 |
| h) have difficulty concentrating |
1 2 3 4 5 |
| i) procrastinate |
1 2 3 4 5 |
| j) feel used, unappreciated |
1 2 3 4 5 |
| k) cynical |
1 2 3 4 5 |
| l) lazy |
1 2 3 4 5 |
| m) don't like the way I look |
1 2 3 4 5 |
| n) don't speak up |
1 2 3 4 5 |
| o) am hostile |
1 2 3 4 5 |
| p) explosive |
1 2 3 4 5 |
| q) feel ashamed of myself |
1 2 3 4 5 |
| r) feel guilty |
1 2 3 4 5 |
| s) feel sorry for myself |
1 2 3 4 5 |
| t) am forgetful |
1 2 3 4 5 |
| u) am not aware of my feelings |
1 2 3 4 5 |
| v) have difficulty expressing negative feelings |
1 2 3 4 5 |
| w) have difficulty expressing positive feelings |
1 2 3 4 5 |
| x) feel easily rejected |
1 2 3 4 5 |
| y) am resentful |
1 2 3 4 5 |
| z) am easily frustrated |
1 2 3 4 5 |
| aa) am a wishful thinker |
1 2 3 4 5 |
| bb) set my goals too high (out of reach) |
1 2 3 4 5 |
| cc) fail to plan |
1 2 3 4 5 |
| dd) am easily confused |
1 2 3 4 5 |
| ee) am depressed |
1 2 3 4 5 |
| ff) impulsive |
1 2 3 4 5 |
| gg) anger easily |
1 2 3 4 5 |
| hh) not aware when I am angry |
1 2 3 4 5 |
| ii) exhausted |
1 2 3 4 5 |
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| THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE. |
