Please note, all fields are required to receive a final result.

How much more or less do you feel you worry about your weight and body shape than other people your age?

I worry a lot less than other people

I worry a little less than other people

I worry about the same as other people

I worry a little more than other people

I worry a lot more than other people

How afraid are you of gaining 3 pounds?

Not afraid of gaining

Slightly afraid of gaining

Moderately afraid of gaining

Very afraid of gaining

Terrified of gaining

When was the last time you went on a diet?

I have never been on a diet

I was on a diet about one year ago

I was on a diet about 6 months ago

I was on a diet about 3 months ago

I was on a diet about 1 month ago

I was on a diet less than 1 month ago

I’m on a diet now

Compared to other things in your life, how important is your weight to you?

My weight is not important compared to other things in my life

My weight is a little more important than some other things in my life

My weight is more important than most, but not all, things in my life

My weight is the most important thing in my life

Do you ever feel fat?

Never

Rarely

Sometimes

Often

Always

In the past 3 months, how many times have you had a sense of loss of control AND you also ate what most people would regard as an unusually large amount of food at one time, defined as definitely more than most people would eat under similar circumstances?

During these episodes of eating an unusually large amount of food with a sense of loss of control, do you:

Eat much more rapidly than normal?

Yes

No

Eat until feeling uncomfortably full?

Yes

No

Eat large amounts of food when not feeling physically hungry?

Yes

No

Eat alone because of feeling embarrassed by how much you are eating?

Yes

No

Feel disgusted, depressed, or very guilty afterward?

Yes

No

How distressed or upset have you felt about these episodes?

Not at all

A little

Moderately

Greatly

Extremely

In the past 3 months, how many times have you done any of the following as a means to control your weight and shape:

Made yourself throw-up?

Used diuretics or laxatives?

Exercised excessively?

Fasted?

Do you consume a small amount of food (i.e., less than 1200 calories/day) on a regular basis to influence your shape or weight?

Yes

No

Do you struggle with a lack of interest in eating or food?

Yes

No

Do you avoid certain or many foods because of such features as texture, consistency, temperature, or smell, or have other people

Yes

No

Do you avoid certain or many foods because of fear of experiencing negative consequences like choking or vomiting, or have other people suggested this may be the case for you?

Yes

No

Have you experienced significant weight loss* but are not overly concerned with the size or shape of your body?

Yes

No

Are you currently in treatment for an eating disorder?

Yes

No

What was your lowest weight in the past year, including today, in pounds??

What is your current weight in pounds??

What is your current height in inches??

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