| Have you developed fears or beliefs about food you never had before? | Yes | No |
| Do you think losing weight would make your life better? | Yes | No |
| Are other people concerned about your weight, eating or exercise habits? | Yes | No |
| Do you often feel fat? | Yes | No |
| Have you changed your eating and exercise because you don’t like your weight? | Yes | No |
| Do most other people eat and/or exercise like you? | Yes | No |
| Are you keeping secrets about how you’re eating or trying to lose weight? | Yes | No |
| Would you eat more than others if you did not control yourself? | Yes | No |
| Do you weigh yourself more than once per week? | Yes | No |
| Does controlling your food or weight make you feel good? | Yes | No |
| Have you ever thought about or actually thrown up after eating? | Yes | No |
| Does having to eat a normal meal scare you? | Yes | No |
| Do you define foods in “good” and “bad” categories? | Yes | No |
| Do you feel you need to get rid of calories after you eat them? | Yes | No |
| Have you ever eaten a large amount of food and felt out of control? | Yes | No |
| Would you rather stay home to eat or exercise instead of spending time with friends? | Yes | No |
| Do you force yourself to starve, exercise or purge when you don’t want to? | Yes | No |
| Have you ever used diet pills or laxatives for weight control or weight loss? | Yes | No |
| Do you think if you eat more calories the weight will go right to your stomach, butt or thighs? | Yes | No |
| Would you ever want your best friend to eat like you do? | Yes | No |
| Do you get angry when others question what or when you’re eating? | Yes | No |
| Can you eat three normal meals a day without feeling anxious, depressed or out of control? | Yes | No |
| Do you eat lots of food when others are not around? | Yes | No |
| Would you feel like a failure if you gained weight or couldn’t diet? | Yes | No |
| Has your weight become a central focus in your life? | Yes | No |
| Do you panic if you can’t exercise? | Yes | No |
| Has your menstrual period changed or stopped? | Yes | No |
| Are you frequently going on diets but not losing weight? | Yes | No |
| Have you ever wondered whether you have an eating disorder? | Yes | No |