Eating Questionnaire

The following questions are concerned with the past four weeks (28 days) only. Please read each question carefully. Please answer all of the questions. Please choose only one answer for each question. Thank you.

Reference: “Cognitive Behavior Therapy and Eating Disorders”, Christopher G. Fairburn, 2008.

Questions 1 to 12: Please circle the appropriate number. Remember that the questions only refer to the past four weeks (28 days) only.

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: Please fill in the appropriate number in the boxes. Remember that the questions only refer to the past four weeks (28 days)..

13. Over the past 28 days, how many times have you eaten what other people would regard as an unusually large amount of food (given the circumstances)?
14. ... On how many of these times did you have a sense of having lost control over your eating (at the time that you were eating)?
15. Over the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time)?
16. Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight?
17. Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight?
18. Over the past 28 days, how many times have you exercised in a “driven” or “compulsive” way as a means of controlling your weight, shape or amount of fat or to burn off calories?

Questions 19-21: Please circle the appropriate number. 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 (ie, 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 of the times A few of the times Less than half Half of the times More than half Most of the time 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
0 (Not at all) 1 (NAA-Slight) 2 (Slightly) 3 (Slight-Mod) 4 (Moderately) 5 (Mod-Mark) 6 (Markedly)
22. Has your weight influenced how you think about (judge) yourself as a person?
0 (Not at all) 1 (NAA-Slight) 2 (Slightly) 3 (Slight-Mod) 4 (Moderately) 5 (Mod-Mark) 6 (Markedly)
23. Has your shape influenced how you think about (judge) yourself as a person?
0 (Not at all) 1 (NAA-Slight) 2 (Slightly) 3 (Slight-Mod) 4 (Moderately) 5 (Mod-Mark) 6 (Markedly)
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?
0 (Not at all) 1 (NAA-Slight) 2 (Slightly) 3 (Slight-Mod) 4 (Moderately) 5 (Mod-Mark) 6 (Markedly)
25. How dissatisfied have you been with your weight?
0 (Not at all) 1 (NAA-Slight) 2 (Slightly) 3 (Slight-Mod) 4 (Moderately) 5 (Mod-Mark) 6 (Markedly)
26. How dissatisfied have you been with your shape?
0 (Not at all) 1 (NAA-Slight) 2 (Slightly) 3 (Slight-Mod) 4 (Moderately) 5 (Mod-Mark) 6 (Markedly)
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)?
0 (Not at all) 1 (NAA-Slight) 2 (Slightly) 3 (Slight-Mod) 4 (Moderately) 5 (Mod-Mark) 6 (Markedly)
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)?
0 (Not at all) 1 (NAA-Slight) 2 (Slightly) 3 (Slight-Mod) 4 (Moderately) 5 (Mod-Mark) 6 (Markedly)

What is your weight at present? (Please give your best estimate): Kg
What is your height? (Please give your best estimate): Cm
If female: Over the past three-to-four months have you missed any menstrual periods?
If so, how many?
Have you been taking the “pill“?

Thank you. Finally, please enter your details then click “Submit”.

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