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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
*
:
Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Body weight
*
:
(Kg)
Body height
*
:
(m)
Nationality
*
:
Hong Kong SAR (香港特別行政區)
Antarctica (南極大陸)
Albania (阿爾巴尼亞)
Argentina (阿根廷)
Afghanistan (阿富汗)
Azerbaijan (亞塞拜然)
Algeria (阿爾巴尼亞)
Angola (安哥拉)
Aruba
Antigua and Barbuda (安提瓜島及巴爾布達島)
Australia (澳洲)
Anguilla (安圭拉島)
Aruba
Armenia (亞美尼亞)
Bahamas (巴哈馬)
Botswana (波札那)
Bermuda (百慕達島)
Bosnia and Herzegovina (波士尼亞及黑賽哥維那)
Belize (貝里斯)
Burundi (蒲隆地)
Benin (貝寧)
Myanmar
Bahrain (巴林)
Bolivia (玻利維亞 )
Barbados (巴貝多)
British Indian Ocean Territory (英屬印度洋領地)
Bhutan (不丹)
Bulgaria (保加利亞)
Bangladesh (孟加拉共和國)
Belgium (比利時)
Fmr USSR-Byelorussia
Brazil (巴西)
Chad (查德)
Central African Republic (中非共和國)
Congo (剛果)
Chile (智利)
China (中國)
Cameroon (喀麥隆)
Canada (加拿大)
Colombia (哥倫比亞)
Costa Rica (哥斯達黎加)
Cuba (古巴)
Cape Verde (佛德角)
Cyprus (賽普勒斯)
Czech Republic (捷克共和國)
Djibouti (吉布地)
Germany (德國)
Denmark (丹麥)
Dominica (多明尼加)
Dominican Republic (多明尼加共和國)
Yemen
Egypt (埃及)
Estonia (愛沙尼亞)
Ecuador (厄瓜多爾)
United Arab Emirates
El Salvador
Ethiopia
Faroe Islands
French Guiana
Finland
Fiji
Falkland Islands
St Pierre and Miquelon
France (法國)
Gambia
Cayman Islands
Grenada
Georgia
Ghana
Gibraltar
Greenland
Guam
Guinea
Gabon
Equatorial Guinea
Greece
Guam
Guatemala
Guinea-Bissau
Guyana
Haiti
St Helena
Honduras
Hungary
Burkina Faso
Indonesia
Ireland
Iceland
India (印度)
Iraq
Iran
Israel
Ivory Coast
Israel
Italy (意大利)
Jordan
Jamaica
Japan (日本)
Micronesia
Kiribati
Kenya
South Korea (南韓)
Cambodia
North Korea (北韓)
Cook Islands
Kuwait
Kazakhstan
Laos
Lebanon
Saint Lucia
Liberia
Lithuania
Latvia
Luxembourg
Libya
Morocco
Montserrat
Guadeloupe
Madagascar
Marshall Islands
Mali
Macedonia
Malta
Monaco
Mongolia
Martinique
Malaysia (馬來西亞)
Mauritania
Macau (澳門)
Maldives Islands
Malawi
Brunei
Mexico (墨西哥)
Mozambique
New Caledonia
Papua-New Guinea
Vanuatu
Nigeria
Nicaragua
Netherlands
Namibia
Norway (挪威)
Nepal (尼泊爾)
Niger
Aruba
Vanuatu
Nauru
New Zealand (新西蘭)
Oman
Austria
French Polynesia
Philippines (菲律賓)
Pakistan
Poland (波蘭)
Panama
Portugal
Peru
Puerto Rico
Paraguay
Qatar
Russia
Reunion and associated islands
Croatia
Romania
Russia
Rwanda
Sri Lanka
Seychelles
Saudi Arabia
Senegal
Somalia
Sierra Leone
Suriname
Sweden
Spain
Slovakia
Singapore (新加坡)
Guadeloupe
Sudan
Swaziland
Switzerland (瑞士)
Syria
Trinidad and Tobago
Togo
Thailand (泰國)
United States of America (美國)
Turks and Caicos Islands
Timor
Tanzania
Tonga
Turkmenistan
Tunisia
Turkey
Tuvalu
Taiwan (台灣)
Tajikistan
Uganda
United Kingdom (英國)
Ukraine
Uruguay
Uzbekistan
Virgin Islands
Venezuela
Vietnam
Yemen
Fmr Yugoslavia
South Africa
Zambia
Samoa
Zaire
Zimbabwe (辛巴威)
Country of current residence
*
:
Hong Kong SAR (香港特別行政區)
Antarctica (南極大陸)
Albania (阿爾巴尼亞)
Argentina (阿根廷)
Afghanistan (阿富汗)
Azerbaijan (亞塞拜然)
Algeria (阿爾巴尼亞)
Angola (安哥拉)
Aruba
Antigua and Barbuda (安提瓜島及巴爾布達島)
Australia (澳洲)
Anguilla (安圭拉島)
Aruba
Armenia (亞美尼亞)
Bahamas (巴哈馬)
Botswana (波札那)
Bermuda (百慕達島)
Bosnia and Herzegovina (波士尼亞及黑賽哥維那)
Belize (貝里斯)
Burundi (蒲隆地)
Benin (貝寧)
Myanmar
Bahrain (巴林)
Bolivia (玻利維亞 )
Barbados (巴貝多)
British Indian Ocean Territory (英屬印度洋領地)
Bhutan (不丹)
Bulgaria (保加利亞)
Bangladesh (孟加拉共和國)
Belgium (比利時)
Fmr USSR-Byelorussia
Brazil (巴西)
Chad (查德)
Central African Republic (中非共和國)
Congo (剛果)
Chile (智利)
China (中國)
Cameroon (喀麥隆)
Canada (加拿大)
Colombia (哥倫比亞)
Costa Rica (哥斯達黎加)
Cuba (古巴)
Cape Verde (佛德角)
Cyprus (賽普勒斯)
Czech Republic (捷克共和國)
Djibouti (吉布地)
Germany (德國)
Denmark (丹麥)
Dominica (多明尼加)
Dominican Republic (多明尼加共和國)
Yemen
Egypt (埃及)
Estonia (愛沙尼亞)
Ecuador (厄瓜多爾)
United Arab Emirates
El Salvador
Ethiopia
Faroe Islands
French Guiana
Finland
Fiji
Falkland Islands
St Pierre and Miquelon
France (法國)
Gambia
Cayman Islands
Grenada
Georgia
Ghana
Gibraltar
Greenland
Guam
Guinea
Gabon
Equatorial Guinea
Greece
Guam
Guatemala
Guinea-Bissau
Guyana
Haiti
St Helena
Honduras
Hungary
Burkina Faso
Indonesia
Ireland
Iceland
India (印度)
Iraq
Iran
Israel
Ivory Coast
Israel
Italy (意大利)
Jordan
Jamaica
Japan (日本)
Micronesia
Kiribati
Kenya
South Korea (南韓)
Cambodia
North Korea (北韓)
Cook Islands
Kuwait
Kazakhstan
Laos
Lebanon
Saint Lucia
Liberia
Lithuania
Latvia
Luxembourg
Libya
Morocco
Montserrat
Guadeloupe
Madagascar
Marshall Islands
Mali
Macedonia
Malta
Monaco
Mongolia
Martinique
Malaysia (馬來西亞)
Mauritania
Macau (澳門)
Maldives Islands
Malawi
Brunei
Mexico (墨西哥)
Mozambique
New Caledonia
Papua-New Guinea
Vanuatu
Nigeria
Nicaragua
Netherlands
Namibia
Norway (挪威)
Nepal (尼泊爾)
Niger
Aruba
Vanuatu
Nauru
New Zealand (新西蘭)
Oman
Austria
French Polynesia
Philippines (菲律賓)
Pakistan
Poland (波蘭)
Panama
Portugal
Peru
Puerto Rico
Paraguay
Qatar
Russia
Reunion and associated islands
Croatia
Romania
Russia
Rwanda
Sri Lanka
Seychelles
Saudi Arabia
Senegal
Somalia
Sierra Leone
Suriname
Sweden
Spain
Slovakia
Singapore (新加坡)
Guadeloupe
Sudan
Swaziland
Switzerland (瑞士)
Syria
Trinidad and Tobago
Togo
Thailand (泰國)
United States of America (美國)
Turks and Caicos Islands
Timor
Tanzania
Tonga
Turkmenistan
Tunisia
Turkey
Tuvalu
Taiwan (台灣)
Tajikistan
Uganda
United Kingdom (英國)
Ukraine
Uruguay
Uzbekistan
Virgin Islands
Venezuela
Vietnam
Yemen
Fmr Yugoslavia
South Africa
Zambia
Samoa
Zaire
Zimbabwe (辛巴威)
Email address
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Confirm email address
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Contact number:
(Mobile Phone)
(Home Phone)
(Office Phone)
Contact address:
Marital status
*
:
Single
Married
Cohabitating
Divorced
Widowed
Educational level
*
:
No schooling
Primary
Secondary
University Degree
Postgraduate
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?
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