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Please enter your personal information,
it will be kept completely confidential.
 
   Your score in the Health Screening Questionnaire is * / 5
    Your score in the Eating Disorder Examination Questionnaire
Restraint of eating is: * / 30
Eating concern is: * / 30
Shape concern is: * / 48
Weight concern is: * / 30

Personal information

 ( * ) Indicates a required field
Login Name*:
Password*:
Confirm password*:
First Name / Given Name*:
Last Name / Surname*:
Gender*: Female            Male
Date of Birth*:
Body weight*: (Kg)
Body height*: (m)
Nationality*:
Country of current residence*:
Email address* :
Confirm email address* :
Contact number: (Mobile Phone)
  (Home Phone)
  (Office Phone)
Contact address:
Marital status*:
Educational level*:
Occupation*: Student
Clerical/Secretarial
Finance
Professional
Sales
Marketing
Research
Unemployed
Other. Please specify
 
History of health *
Are you currently suffering from any medical disorder or undergoing treatment which may affect your eating habits or weight?

If yes, what is the disorder or treatment and for how long you have it? Please specify:
 		Yes No
Are you receiving any specialist treatment on eating disorders apart from seeing a general practitioner or psychiatrist?

If yes, what is the specialist treatment and for how long you have received it? Please specify:
 Yes No
Are you taking any medication for the treatment of eating disorder?

If yes, what medication you are taking and for how long you have been taking it? Please specify:
 Yes No
Are you suffering any major psychological disorder?

If yes, what is the major psychological disorder and for how long you have the disorder? Please specify:
 Yes No
Are you in a state of a medical emergency caused by the complications of an eating disorder?

If yes, please describe your condition in below:
 		Yes No
Self-help programme*
How did you hear about this self-help programme?

Are you certified by a general practitioner or psychiatrist that you are suitable for the self-help programme?
Yes
No
If yes, who is the general practitioner or psychiatrist?