Questions 1-12: Frequency Over Past 28 Days
Please circle the appropriate number. Remember that the questions only refer to the past four weeks (28 days).
1
Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
2
Have you gone for long periods of time (8 waking hours or more) without eating anything at all in order to influence your shape or weight?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
3
Have you tried to exclude from your diet any foods that you like in order to influence your shape or weight (whether or not you have succeeded)?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
4
Have you tried to follow definite rules regarding your eating (for example, a calorie limit) in order to influence your shape or weight (whether or not you have succeeded)?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
5
Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
6
Have you had a definite desire to have a totally flat stomach?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
7
Has thinking about food, eating or calories made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
8
Has thinking about shape or weight made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
9
Have you had a definite fear of losing control over eating?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
10
Have you had a definite fear that you might gain weight?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
11
Have you felt fat?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
12
Have you had a strong desire to lose weight?
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
Questions 13-18: Frequency Counts
Please fill in the appropriate number. Remember that the questions only refer to the past four weeks (28 days).
Questions 19-21: Additional Behaviors
Please note that for these questions the term "binge eating" means eating what others would regard as an unusually large amount of food for the circumstances, accompanied by a sense of having lost control over eating.
19
Over the past 28 days, on how many days have you eaten in secret (i.e., furtively)? Do not count episodes of binge eating.
No Days
1-5 Days
6-12 Days
13-15 Days
16-22 Days
23-27 Days
Every Day
20
On what proportion of the times that you have eaten have you felt guilty (felt that you've done wrong) because of its effect on your shape or weight? Do not count episodes of binge eating.
None
A Few
Less Than Half
Half
More Than Half
Most
Every Time
21
Over the past 28 days, how concerned have you been about other people seeing you eat? Do not count episodes of binge eating.
Not At All
Slightly
Moderately
Markedly
Very Markedly
Extremely
Completely
Questions 22-28: Importance and Severity
Please circle the appropriate number. Remember that the questions only refer to the past four weeks (28 days).
22
Has your weight influenced how you think about (judge) yourself as a person?
Not At All
Slightly
Moderately
Markedly
Very Markedly
Extremely
Completely
23
Has your shape influenced how you think about (judge) yourself as a person?
Not At All
Slightly
Moderately
Markedly
Very Markedly
Extremely
Completely
24
How much would it have upset you if you had been asked to weigh yourself once a week (no more, or less, often) for the next four weeks?
Not At All
Slightly
Moderately
Markedly
Very Markedly
Extremely
Completely
25
How dissatisfied have you been with your weight?
Not At All
Slightly
Moderately
Markedly
Very Markedly
Extremely
Completely
26
How dissatisfied have you been with your shape?
Not At All
Slightly
Moderately
Markedly
Very Markedly
Extremely
Completely
27
How uncomfortable have you felt seeing your body (for example, seeing your shape in the mirror, in a shop window reflection, while undressing or taking a bath or shower)?
Not At All
Slightly
Moderately
Markedly
Very Markedly
Extremely
Completely
28
How uncomfortable have you felt about others seeing your shape or figure (for example, in communal changing rooms, when swimming, or wearing tight clothes)?
Not At All
Slightly
Moderately
Markedly
Very Markedly
Extremely
Completely