Health Survey Questionnaire

Name *

First Name

Last Name

Even when you’re hungry, do you avoid eating? *

Yes

No

After you’re full, do you continue to eat? *

Yes

No

Do you exercise even when you're sick? *

Yes

No

Do you judge yourself based on how you see your body shape and size? *

Yes

No

Do you force yourself to vomit to get rid of unwanted calories? *

Yes

No

Do you use food to cope with emotions?

Yes

Yes

Do you feel as if food is controlling your life?

Yes

No

Do you feel guilty after you eat?

Yes

No

Are you a repeat dieter? *

Yes

No

Does eating make you feel out of control? *

Yes

No

Do you skip meals in order to avoid gaining weight?

Yes

No

Are you preoccupied with food? *

Yes

No

Do you hide food or eat in secret? *

Yes

No

Do you weigh yourself at least once a day? *

Yes

No

Do you take diuretics or laxatives to lose weight? *

Yes

No

Do you eat large amounts of food at one time? *

Yes

No

Would you like to be contacted? *

Yes

No

Phone Number

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