Section 1 — Eating Habits & Restraint
On how many of the past 28 days...
1Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)?
2Have 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?
3Have 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)?
4Have 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)?
5Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight?
6Have you had a definite desire to have a totally flat stomach?
7Has 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)?
8Has 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)?
9Have you had a definite fear of losing control over eating?
10Have you had a definite fear that you might gain weight?
12Have you had a strong desire to lose weight?
Section 3 — Eating in Secret & Social Concern
Do not count episodes of binge eating for questions 19-21.
19Over the past 28 days, on how many days have you eaten in secret (i.e., furtively)?
20On what proportion of the times that you have eaten have you felt guilty (felt that you've done wrong) because of its effect on your shape or weight?
21Over the past 28 days, how concerned have you been about other people seeing you eat?
Not at allSlightlyModeratelyMarkedly
Section 4 — Shape & Weight Concern
On how many over the past 28 days...
22Has your weight influenced how you think about (judge) yourself as a person?
Not at allSlightlyModeratelyMarkedly
23Has your shape influenced how you think about (judge) yourself as a person?
Not at allSlightlyModeratelyMarkedly
24How much would it have upset you if you had been asked to weigh yourself once a week (no more, or less, often) for the next four weeks?
Not at allSlightlyModeratelyMarkedly
25How dissatisfied have you been with your weight?
Not at allSlightlyModeratelyMarkedly
26How dissatisfied have you been with your shape?
Not at allSlightlyModeratelyMarkedly
27How uncomfortable have you felt seeing your body (for example, seeing your shape in the mirror, in a shop window reflection, while undressing or taking a bath or shower)?
Not at allSlightlyModeratelyMarkedly
28How uncomfortable have you felt about others seeing your shape or figure (for example, in communal changing rooms, when swimming, or wearing tight clothes)?
Not at allSlightlyModeratelyMarkedly