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Eating Disorder Evaluation

This survey is designed to gather information in significant areas of your life. This information is very important in helping to determine what level of care is appropriate for your needs. Your honesty in answering these questions is a significant step in beginning the process of recovery.

After filling out the survey you will receive a score immediately and recommendations based upon your score.

We want you to know regardless of how high your score is, There is Hope! After taking this evaluation survey you will also be able to e-mail The Center your score to receive feedback from The Center including suggestions on how to obtain help to overcome an Eating Disorder.

NeverSome-
times
Often
1) Do you have uncontrollable urges to eat and eat until physically ill?
2) Do you have episodes of eating a large amount of food in a short time (bingeing)?
3) Do you induce vomiting to get rid of food eaten?
4) Do you eat normal meals without bingeing and/or vomiting?
5) Do you use laxatives to control your weight or to get rid of food?
6) Do you "spit out" food after chewing in order to prevent digestion?
7) Do you use diet pills to control your weight?
8) Do you use water pills (diureticsto control your weight?
9) Do you use exercise to control your weight?
10) Do you use fasting to control your weight?
11) Do you use enemas to control your weight?
12) Do you use "fad" diets to control your weight?
13) Do you use restricting calories to control your weight?
14) Are you obsessed or preoccupied with what you are eating and with dieting?
15) Do you use Alcohol?
16) Do you use Amphetamines?
17) Do you use Barbituates?
18) Do you use Hallucinogens?
19) Do you use Marijuana?
20) Do you use Tranquilizers?
21) Do you use Cocaine?
22) Do you use Methamphetamine?
23) Do you use Cigarettes?
24) Do you feel you have a drug and/or alcohol problem?
25) Do you have thoughts of physically harming yourself?
26) Do you have thoughts of ending your life?
27) Are you unwilling to gain ten pounds in exchange for not bingeing/purging?
28) Do you eat Bread/cereal/pasta during a binge?
29) Do you eat Cheese/milk/yogurt during a binge?
30) Do you eat fruit during a binge?
31) Do you eatMeat/poultry/fish/eggs during a binge?
32) Do you eat vegetables during a binge?
33) Do you eat Salty "snack" foods (e.g., chips, pretzels, popcorn, etc.during a binge?
34) Do you eat Sweets (foods high in sugarduring a binge?
35) Do you eat Bread/cereal/pasta when not bingeing?
36) Do you eat Cheese/milk/yogurt when not bingeing?
37) Do you eat Fruit when not bingeing?
38) Do you eat Meat/poultry/fish/eggs when not bingeing?
39) Do you eat Vegetables when not bingeing?
40) Do you eat Salty "snack" foods when not bingeing ?
41) Do you eat sweets when not bingeing?
42) Do you often feel tired?
43) Do you feel hungry between meals?
44) Do you find yourself depressed at night?
45) Do you wake up after a few hours of sleep?
46) Do you feel you can't concentrate?
47) Do you feel moody?
48) Do you eat candy, drink soda or coffee between meals or in mid-afternoon?
49) Do you eat bread, pasta, potatoes, rice or beans?
50) Do you consume alcohol?
51) Do you drink more than three cups of coffee or cola drinks per day?
52) Do you crave candy, soda or coffee between meals or in mid-afternoon?
53) Do you have headaches?
54) Do you have fits of anger?
55) Do you feel sleepy or drowsy after meals?
56) Do you feel a lack of energy?
57) Do you feel fatigue relieved by eating?
58) Do you feel irritable before meals?
59) Do you get shaky inside when hungry?
60) Do you feel faint if meal is delayed?
61) Do you have ulcers, gastritis, chronic indigestion, abdominal bloating?
62) Do you have cold hands or feet?
63) Do your hands tremble or shake?
64) Do you have blurred vision?
65) Do you feel dizzy, giddy or light-headed?
66) Have you ever taken tetracycline or other antibiotics for acne for one month or longer?
67) Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis or other problems affecting your reproductive organs?
68) Have you taken prednisone or other cortisone-type drugs for more than two weeks?
69) Have you taken birth-control pills for six months to two years?
70) Does exposure to perfumes, insecticides, fabric shop odors or other chemicals provoke mild symptoms?
71) Are your symptoms worse on damp, muggy days or in moldy places?
72) Have you had athlete's foot, ring-worm, "jock-itch," or other chronic fungal infections of the skin or nails?
73) Have the infections been severe or persistent?
74) Do you crave sugar?
75) Do you crave breads?
76) Do you crave alcoholic beverages?
77) I don't know what's going on inside me.
78) I am terrified of gaining weight (losing control).
79) The demands of adulthood are overwhelming.
80) The best years of life are when you are a child.
81) I feel alone in the world.
82) I can clearly identify what emotion I am feeling.
83) I feel I don't have enough satisfying relationships.
84) I feel I must do things perfectly or not at all.
85) I feel out of control of my life (eating).
86) Others have expected perfection of me.
87) I feel guilty after over-eating.
88) I feel unsatisfied with the shape of my body.
89) I have been hospitalized previously for "emotional problems."
90) I have difficulty expressing my emotions to others.
91) I have thrown-up to the point of seeing blood.
92) I wish I were someone else.
93) I feel fat.
94) I feel people would reject me if they knew the "real" me.
95) I am unhappy with my accomplishments.
96) I have thought about harming another person.
97) I have gone on binges where I felt I could not stop eating.
98) I feel worthless as a person.
99) I feel I cannot live up to others' expectations of me.
100) The pressures of life are too overwhelming at times.
101) I've attempted suicide.