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The following questions are concerned with the past four weeks (28 days) only. Please read each question carefully.
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On how many of the past 28 days...
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Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight?
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Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight?
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Have you gone for long periods of time (8 waking hours or more) without eating anything at all in order to influence your weight
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Have you tried to exclude from your diet any foods that you like in order to influence your shape or weight?
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Have you tried to follow definite rules regarding your eating (ex: calorie limit) in order to influence your shape or weight?
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Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight?
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Have you had a definite desire to have a totally flat stomach?
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Has thing about food, eating, or calories made it very difficult concentrate on things you are interested in?
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Has thinking about shape or weight made it very difficult to concentrate on things you are interested in?
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Have you had a definite fear of losing control overeating?
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Have you had a definite fear that you might gain weight?
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Have you felt fat?
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Have you had a strong desire to lose weight?
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Questions 13-18 Please fill in with the appropriate number in the boxes to the right.
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Over the past four weeks (28 days)
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Over the past 28 days, how many times have you eaten what other people would regard as an unusually large amount of food?
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On how many of these times did you have a sense of having lost control over your eating?
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Over the past 28 days, on how many days have such episodes of overeating occurred?
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Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight?
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Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight?
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Over the past 28 days, how many times have you exercised in a driven or compulsive way as a means of controlling your weight?
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Questions 19-21 Please select the appropriate response for each question.
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Over the past 28 days, on how many days have you eaten in secret?
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On what proportion of the times that you have eaten have you felt guilty because of its effect on your shape or weight?
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Over the past 28 days, how concerned have you been about other people seeing you eat?
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Questions 22-28 Please select the appropriate response to the right.
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Over the past 28 days...
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Has your weight influenced how you think about (judge) yourself as a person?
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23. Has your shape influenced how you think (judge) yourself as a person?
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24. How much would it have upset you if you had been asked to weigh yourself once a week for the next four weeks?
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25. How dissatisfied have you been with your weight?
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26. Have you been dissatisfied with your shape?
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27. How uncomfortable have you felt seeing your body?
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28. How uncomfortable have you felt about others seeing your shape or figure?
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What is your weight at present? (Please give your best estimate)
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What is your height? (Please give your best estimate)
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If female: Over the past 3 to 4 months, have you missed any menstrual periods?
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If so, how many?
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