| Instructions: This is a screening measure
to help you determine whether you
might have an eating disorder that needs professional attention.
This screening measure is not
designed to make a diagnosis of an eating disorder or take the
place of a professional consultation.
Please fill out the form below as accurately, honestly and completely
as possible. There are no right
or wrong answers. If you notice problematic areas consider seeking
help!
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| Part B: Check a response for each of
the following statements: |
Always: |
Usually: |
Often: | Some
times:
| Rarely: |
Never: |
1. |
Am terrified about
being overweight. |
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2. |
Avoid eating when I am hungry.
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3. |
Find myself preoccupied with food.
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4. |
Have gone on eating binges where I
feel that I may not be able to stop. |
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5. |
Cut my food into small pieces.
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6. |
Aware of the calorie content of foods
that I eat. |
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7. |
Particularly avoid food with
a high carbohydrate content (i.e. bread, rice, potatoes,
etc.) |
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8. |
Feel that others would prefer if I
ate more. |
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9. |
Vomit after I have eaten.
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10. |
Feel extremely guilty after eating.
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11. |
Am occupied with a desire to be thinner.
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12. |
Think about burning up calories when
I excercise. |
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13. |
Other people think that I am too thin.
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14. |
Am preoccupied with the thought of
having fat on my body. |
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15. |
Take longer than others to eat my meals.
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16. |
Avoid foods with sugar in them.
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17. | Eat diet foods. |
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18. |
Feel that food controls my life.
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19. |
Display self-control around food.
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20. |
Feel that others pressure me to eat.
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21. |
Give
too much time and thought to food. |
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22. |
Feel uncomfortable after eating
sweets. |
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23. | Engage
in dieting behavior.
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24. |
Like
my stomach to be empty. |
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25. | Have the impulse to vomit after
meals. |
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26. | Enjoy
trying new rich foods.
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Part C: Behavioral Questions:
In the past 6 months have you:
| Never | Once a month or less |
2-3
times a month | Once a week |
2-6
times a week | Once a day or more |
A. |
Gone on eating binges
where you feel that you may not be able to stop?*
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B. |
Ever
made yourself sick (vomited) to control your weight
or shape? |
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C. |
Ever used laxatives, diet pills or
diuretics (water pills) to control your
weight or shape? |
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D. | Exercised
more than 60 minutes a day to
lose or to control your weight? |
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E. |
Lost 20 pounds or more in the
past 6 months |
YES
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NO
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*Defined as eating much more than most
people would under the same circumstances
and feeling that eating is out of control. |
