Questionnaire (Eating)

Hello! Please click the button below to complete a short questionnaire. Doing this regularly is one way we can track how therapy is going. Your responses will be emailed directly to Dr Forzisi.

Instructions: 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 only choose one answer for each question. Thank you.
Questions 1 to 12: Please select the appropriate number for each question. Remember that the questions only refer to the past four weeks (28 days) only.
On how many of the past 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)? *
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = 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? *
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = 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)? *
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = 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)? *
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = Every day
5. Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight? *
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = Every day
6. Have you had a definite desire to have a totally flat stomach? *
0 = None 1 = Less than 1 hour per day 2 = 1-3 hours per day 3 = 3-8 hours per day 4 = More than 8 hours per 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)? *
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = 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)? *
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = Every day
9. Have you had a definite fear of losing control over eating? *
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = Every day
10. Have you had a definite fear that you might gain weight? *
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = Every day
11. Have you felt fat?
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = Every day
12. Have you had a strong desire to lose weight?
0 = No days 1 = 1-5 days 2 = 6-12 days 3 = 13-15 days 4 = 16-22 days 5 = 23-27 days 6 = Every day