Initial of First name:

       Age:

Email address:

Education Completed:

--Select-- K-6 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade High School Grad Vocation/Technical School Some College College Graduate Some Post Graduate Post Graduate Degree

Marital Status:

single married separated divorced widowed

My occupation/profession is:

Are you employed now?:

yes no

I am (click all that apply):

overeater
binge eater
bulimic
anorexic
other
if other, please describe:

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:

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?

Looking back, at what age do you first recall having problems with dieting, body image, weight?

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

CODE HINT: number three, uppercase "X", lowercase "d"

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THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE.