S E C T I O N     A   ---   F E E L I N G S

Are you a perfectionist, a person who always wants to be in control, an overachiever and/or do you think no matter what you do it is never enough?

YES

NO

MAYBE

Do you find that you seek or desire acceptance and/or approval from people, and/or that you have a hard time saying "no"?

YES

NO

MAYBE

Do you find that you are always questioning your own judgements and/or actions, and/or do you scrutinize yourself over small faults?

YES

NO

MAYBE

Do you think you are not good enough, stupid and/or worthless or that people are always judging you in a negative way?

YES

NO

MAYBE

Do you hide your feelings and/or opinions from people for fear of being judged negatively, and/or do you feel like a burden to others with your problems?

YES

NO

MAYBE

Within your family and/or circle of friends are you considered "the strong one" who everyone will come to with problems, and/or you never seem to talk much about your own?

YES

NO

MAYBE

Do you think life would be better and/or people would like you more if you were thin/thinner?

YES

NO

MAYBE

Do you find yourself often comparing your appearance and weight to others, strangers and/or models and actors, and wishing to be as "nice looking" or as "thin" as they are?

YES

NO

MAYBE

Do you continuously feel that you are overweight even though others have told you that you are not?

YES

NO

MAYBE

Do family members and/or friends often express concern for your weight-loss/gain, your appearance, and/or your eating habits?

YES

NO

MAYBE

Do you think everyone's problems are more important then your own, or do you belittle your own emotions and pain?

YES

NO

MAYBE

Do you often feel numb or empty inside, like your life lacks fulfillment and happiness, like something is missing or there is a void inside?

YES

NO

MAYBE

Do you feel as though you have a "conscience" or "voice" that tells you negative things about yourself, convinces you that you do not deserve to eat and/or to be happy, or that tells you that you are or deserve to be fat and ugly?

YES

NO

MAYBE

Examining yourself and how you feel, do you believe that you may suffer from Anorexia, Bulimia or Compulsive Overeating, or any combination of the three?

YES

NO

MAYBE

Do you suffer from bouts of depression, hopelessness, and/or lack of motivation; and/or do you find your own problems overwhelming and hard to handle?

YES

NO

MAYBE

Are you depressed, suicidal, stressed-out, and/or fatigued; and/or do you suffer from anxiety or panic attacks, mood swings, rage and/or insomnia.

YES

NO

MAYBE

Have you ever been diagnosed with clinical depression, attentive deficit disorder, manic depression, bipolar II disorder, post traumatic stress disorder, obsessive compulsive disorder, or dissociative identity disorder, or any other psychological/neurological illness?

YES

NO

MAYBE

S E C T I O N     B   ---   B E H A V I O R S

"PURGING" IS DEFINED AS ANY BEHAVIOR USED TO TRY TO RID THE BODY OF FOOD (AND SOMETIMES FEELINGS) - THIS INCLUDES SELF-INDUCED VOMITING, RESTRICTION AND STARVATION OR FASTING PERIODS AFTER BINGING, COMPULSIVELY EXERCISING, TAKING LAXATIVES OR DIURETICS, ETC.

Do you eat, self-starve or restrict, binge and/or purge, and/or compulsively exercise when you are feeling lonely, badly about yourself or about a situation, or when you are feeling emotional pressures?

YES

NO

MAYBE

While eating, self-starving, or binging and/or purging do you feel comforted, relieved, like emotional pressures have been lifted, or like you are in more control?

YES

NO

MAYBE

Do you feel guilty following a binge and/or purge episode, after eating or during and/or after periods of restriction/self-starvation?

YES

NO

MAYBE

When eating do you ever feel out of control or like you will lose control and not be able to stop; and/or do you try to avoid eating because of this fear?

YES

NO

MAYBE

Do you typically feel guilty after a binge, or after any snack or meal, and like you have almost instantly gained weight, like you are a failure, and/or like you have sabotaged yourself?

YES

NO

MAYBE

Do you use self-starvation, purging, diet pills, laxatives, diuretics, and/or obsessive exercise as a way to attempt to lose weight?

YES

NO

MAYBE

Do you drink a lot of water, tea or coffee, eat a lot of candy or junk food and/or gum, smoke, and/or take caffeine pills as an attempt to control appetite and/or feel more energetic?

YES

NO

MAYBE

Do you abuse alcohol, drugs or prescription medication, and/or practice in self-hurting behavior such as cutting?

YES

NO

MAYBE

Do you weigh yourself often and does the number on the scale dictate your mood and/or self-worth for the day; and/or do you find you are continuously trying to get that number lower?

YES

NO

MAYBE

Are you constantly "on a diet", and/or counting calories and fat grams; and/or do you feel like you've tried every "fad diet" or "lose weight quick" scheme?

YES

NO

MAYBE

Do you set weight-goals for yourself only to find when you reach it that you want to lose more?

YES

NO

MAYBE

Do you do any of the following: hide and/or steal food, laxatives and/or diet pills; eat and/or exercise secretively; avoid eating in public or around others; wear clothes that hide your weight; and/or make excuses (like "I don't feel well) to avoid meals?

YES

NO

MAYBE

Are you secretive about your eating practices, do you think they are abnormal, and/or would you avoid recommending your methods to a family member or friend?

YES

NO

MAYBE

Would you worry about a friend or family member that came to you with similar weight-loss/coping methods?

YES

NO

MAYBE

Do you lie about your eating behaviors, hide them from others at all costs, and/or would you lie or steal to see they could continue?

YES

NO

MAYBE

Do you use self-injury (cutting yourself, burning yourself, pulling out your own hair) as a way to cope with things?

YES

NO

MAYBE

Do you spend a lot of time obsessively cooking for others or reading recipes, and/or studying the nutritional information on food (calories, fat grams, etc.)?

YES

NO

MAYBE

Do you do one or more of the following [harmful] Eating Disorder behaviors: Restrict food intake or starve yourself (eat very little, eat nothing, or try to eat as little as possible); Binge (eat large quantities of food in a short period of time); Purge (use methods such as self-induced vomiting or laxatives to attempt to "get rid of" what you've eaten); Compulsively Overeat (eat even if you are not hungry) Compulsively Exercise (exercise too much, too vigourously, or where it is intrusive in your life); Take diet pills, laxatives, diuretics or other pills or harmful substances to help you curb appetite or assist in purging; Chewing/Spitting (putting food in your mouth, chewing it up and then spitting it out -- this is another form of binging/purging)

YES

NO

MAYBE

S E C T I O N     C   ---   P H Y S I C A L     S I G N S

Are you temperature sensitive (always feel cold or hot), and/or do you get tingling in you extremities (hands and feet)?

YES

NO

MAYBE

Do you find that you bruise easily, have a very high tolerance for pain, and/or you are extremely noise sensitive (even only slightly loud noises irritate you).

YES

NO

MAYBE

Are you unrealistically tired relative to the amount of energy expended (ex. do you feel winded or dizzy after climbing a flight of stairs), and/or do you find yourself often fatigued?

YES

NO

MAYBE

Do you suffer any of the following: heart palpitations and/or chest pains; fainting spells, blackouts or dizziness; chronic lower back pain, headaches or lightheadedness, tingling in arms or legs, numbness in face or other parts of the body, joint pain, excitability, mood swings, hyperactivity; low blood pressure and/or body temperature or escalated blood pressure or cholesterol; and/or chronically sick with cold or flu symptoms.

YES

NO

MAYBE

Do you suffer any of the following: disruption in menstrual cycle and/or irregularity, infertility, decreased sex drive, irritability; lack of ability to concentrate, blurred vision; kidney and/or urinary tract infections; sore throats, dental problems; stomach cramping, blood in stools or vomit, diarrhea, constipation and/or incontinence (loss of bowel control); insomnia, fatigue, and/or anxiety or depression?

YES

NO

MAYBE

When you click "PRINT ANSWERS TO SCREEN" a new page will open that you can print out and take to your doctor or therapist, or keep for yourself. You answers are NOT sent anywhere (electronically or otherwise) but back to only you and only on the screen. The results are not e-mailed to anyone, or stored electronically. Visit other areas of the site such as Signs and Symptoms, Reaching Out, and the definitions of Anorexia, Bulimia and Compulsive Overeating.