Wufoo

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Questionnaire

Fill out this section to be properly evaluated by CEDC.
How often do you weigh yourself? *
Never A couple of times a year About once a month A couple of times a week Daily Two or more times daily
Check the statement that best describes you: *
Weight/body shape is not at all important to how I feel about myself Weight/body shape plays a small part in how I feel about myself Weight/body shape plays a moderate part in how I feel about myself Weight/body shape plays a significant part in how I feel about myself Weight/body shape is the most important thing that affects how I feel about myself
How would gaining 5 pounds make you feel? *
Not upset at all Slightly upset Moderately upset Extremely upset
Since you can remember, how much time have you spent dieting? *
All or nearly all the time About three quarters of the time About half the time About quarter of the time Hardly any/none of the time
How do you feel if you missed a plan day of exercise? *
I don’t know, because I rarely miss a day of exercise, even if I’m not feeling well I feel secretly relieved because I don’t like working out I don’t feel anything one way or the other, it’s just a missed day I feel disappointed, but I know missing a day isn’t a big deal I feel guilt and/or worry greatly about weight gain
Have you done any of the following to control weight?
Cut out whole food groups (such as carbs or red meat) *
Yes No
Counted the calories of every single food you ate *
Yes No
Restricted yourself to less than 1,200 calories/day *
Yes No
Ate only a small variety of foods or the same things every day *
Yes No
Ate only no low‐cal or fat‐free foods *
Yes No
Skipped meals *
Yes No
Used diet pills or diuretics (water pills) *
Yes No
Purged when you felt full *
Yes No
Used laxatives *
Yes No
Do you hold yourself to food rules, such as not eating after a certain time each night or never allowing yourself to eat dessert? *
Yes No
Which of the following do you agree with? *
I only eat when I’m hungry I rarely eat when I’m not hungry I sometimes eat when I’m not hungry
Have you ever had eating binges, when you ate what most people would regard as an unusually large amount of food within a two‐hour period? *
No Rarely (fewer than two or three times a year) On occasion (about six times a year Sometimes (about once/month) Often (about once/week) Almost Daily
Have you done any of the following?
Told someone I’d already eaten, even though I hadn’t, so I wouldn’t have to eat with them *
Yes No
Told someone I weighed less than I did *
Yes No
Told someone I weighed more than I did *
Yes No
Eaten a small amount with others, then gone home and eaten more alone *
Yes No
Have you ever binged, purged or restricted your food intake when you were having strong emotions? *
Yes No
Do you use your food intake as a way of getting more control in your life? *
Yes No
Have you ever had a period of time when you weighed much less than what other people thought you should weigh? *
Yes No
How often do you think about food or eating? *
Yes No
How often do you think about food or eating? *
Yes No
Thank You!

When you're finished, we will evaluate your score to see whether your eating habits and attitudes put you at risk. Our entire staff is available to give you advice and support to help you be happier and healthier. If you have any questions, comments or concerns please call us at 617-547-2255.
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Wufoo

Questionnaire

Have you done any of the following to control weight?

Have you done any of the following?

Thank You!