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Initial of First name: |
Age:
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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?: |
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:
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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
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b) strong need for recognition, approval and reward |
1
2
3
4
5
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c) blame others when things go wrong |
1
2
3
4
5
|
d) am frequently disappointed in friends, family |
1
2
3
4
5
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e) isolate from others |
1
2
3
4
5
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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
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r) feel guilty |
1
2
3
4
5
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s) feel sorry for myself |
1
2
3
4
5
|
t) am forgetful |
1
2
3
4
5
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u) am not aware of my feelings |
1
2
3
4
5
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v) have difficulty expressing negative feelings |
1
2
3
4
5
|
w) have difficulty expressing positive feelings |
1
2
3
4
5
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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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CODE HINT: uppercase "A", lowercase "x", lowercase "q", uppercase "T"
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THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE. |
