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EATING QUESTIONNAIRE
Instructions:
The following questions are concerned with the past four weeks (28 days) only.
Please read each question carefully.
Please answer all of the questions. Thank you.
 
Question 1 to 12: Please select the appropriate answer. Remember that the questions only refer to the past four weeks (28 days) only.
On how many of the past 28 days
1. Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
2. Have 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?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
3. Have 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)?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
4. Have 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)?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
5. Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
6. Have you had a definite desire to have a totally flat stomach?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
7. Has 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)?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
8. Has 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)?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
9. Have you had a definite fear of losing control over eating?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
10. Have you had a definite fear that you might gain weight?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
11. Have you felt fat?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
12. Have you had a strong desire to lose weight?

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
 
Question 13 to 18: Please fill in the appropriate number in the boxes. Remember that the questions only refer to the past four weeks (28 days).Over the past four weeks (28 days) ...
13. Over the past 28 days, how many times have you eaten what other people would regard as an unusually large amount of food (given the circumstances)?
 (Please fill in number, eg. 0,1,2,3)
14. On how many of these times did you have a sense of having lost control over your eating (at the time that you were eating)?
 (Please fill in number, eg. 0,1,2,3)
15. Over that past 28 days, on how many DAYS have such episodes of overeating occurred (i.e., you have eaten an unusually large amount of food and have had a sense of loss of control at the time)?
 (Please fill in number, eg. 0,1,2,3)
16. Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight?
 (Please fill in number, eg. 0,1,2,3)
17. Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight?
 (Please fill in number, eg. 0,1,2,3)
18. Over the past 28 days, how many times have you exercised in a "driven" or "compulsive" way as a means of controlling your weight, shape or amount of fat, or to burn off calories?
 (Please fill in number, eg. 0,1,2,3)
 
Questions 19 to 21: Please select the appropriate answer. Please note that for these questions the term "binge eating" means eating what others would regard as an unusually large amount of food for the circumstances, accompanied by a sense of having lost control over eating.
19. Over the past 28 days, on how many days have you eaten in secret (i.e., furtively)?
Do not count episodes of binge eating

No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
20. On what proportion of the times that you have eaten have you felt guilty (felt that youˇ¦ve done wrong) because of its effect on your shape or weight?
Do not count episodes of binge eating

None of
the times
A few of
the times
Less
than half
Half of
the times
More
than half
Most of
the time
Every time
21. Over the past 28 days, how concerned have you been about other people seeing you eat?
Do not count episodes of binge eating

 
Questions 22 to 28: Please select the appropriate answer. Remember that the questions only refer to the past four weeks (28 days).
22. Has your weight influenced how you think about (judge) yourself as a person?

23. Has your shape influenced how you think about (judge) yourself as a person?
24. How 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?

25. How dissatisfied have you been with your weight?

26. How dissatisfied have you been with your shape?

27. How 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)?

28. How uncomfortable have you felt about others seeing your shape or figure (for example, in communal changing rooms, when swimming, or wearing tight clothes)?

 
29. What is your weight at present? (Please give your best estimate.)
kg
30. What is your height? (Please give your best estimate.)
m
31. If female: Over the past three-to-four months have you missed any menstrual periods?  
32. If so, how many?  
33. Have you been taking the "pill"?  
 
Source:
Fairburn, C.G. & Beglin, S. J. (1994). The assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders, 16, 363-370.