Eating Disorder Questionnaire

Please answer the questionnaire honestly, as it will help to assess possible issues you may have with eating or related behaviors.  Please count the number of “Yes” answers for each section below.

Section One

1. Have you found it difficult or refused to maintain or gain weight despite being told by a health care professional that you were underweight?
2. Are you afraid of gaining weight or becoming “fat”?
3. For women, have you had three or more months without a menstrual cycle (not applicable to those who are post-menopausal, post-hysterectomy or are unable to due to other medical reasons)?
4. Have you skipped one or more meals regularly in order to influence the way you look, i.e. lose weight, etc.?
5. Have you attempted to follow definite rules regarding your eating in order to influence the way you look, i.e. a calorie limit or a set amount of food you may eat?
6. Has thinking about food or its calorie content interfered with your ability to concentrate on things you are interested in, i.e. not paying attention at work/school or when someone is speaking to you? 

Section Two

1. Have there been times when you have eaten what most people would regard as an unusually large amount of food, feeling out of control or unable to stop yourself?
2. Have you eaten a “larger than usual” amount of food than most people would eat in a relatively short period of time (e.g. within a 2 hour period)?
3. Have you made yourself sick (vomit), taken laxatives, diet pills, diuretics, enemas or any other medication as a means of controlling your weight two or more times a week?
4. Have you exercised as a means of controlling the way you look or to counteract the effects of eating, even if you were tired, injured or advised by a health care professional that you should not? 

Section Three

1. Do you hate the way your body looks or feel like your body isn’t attractive, despite others telling you that it looks fine?
2. Have you ever been diagnosed with an eating disorder before, and if so, are some of those same symptoms returning?
3. Do you notice at least one of the following symptoms with your body?
   
   

   Abdominal complaints; bloating Diarrhea Constipation Easy bruising Dry Skin Dehyradation Scalpel Hair Loss Presence of Fine Body Hair Dental or Gum Deterioration Salivary Gland Enlargement Heart Palpitations Osteoporosis (as advised by a health professional)

   Skipped Heart Beats Chest Pain Weakness Lightheadedness Blackouts Fatigue, decreased energy Headaches Cold Intolerance Vomiting Blood Lack of Menstrual Cycle

   
   
4. Do you spend an average of at least 1-2 hours or more each day thinking about or doing the behaviors mentioned in this questionnaire?

If you answered “Yes” to at least three questions in either Section One or Two, or “Yes” to any one of the questions in Section Three, you may have an eating disorder.  We suggest that you print a copy of this questionnaire and make an appointment with a health care professional for an assessment.  You may choose to call someone at the Center for Personal Growth at 619-528-8005 or email us to get more information.  We hope to become your partner in your health.