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* 1. What is your first name?

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* 2. What are your initials?

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* 3. What is your email address?

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* 4. What is your phone # ?

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* 5. Age

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* 6. Gender

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* 7. Weight

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* 8. What is the maximum amount of weight (in pounds) you have lost in one month?

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* 9. What is your maximum weight gain within one week?

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* 10. In a typical week, how much does your weight fluctuate?

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* 11. How many pounds over your ideal weight were you at your maximum weight?

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* 12. In general, how often are you dieting?

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* 13. Would a weight fluctuation of 5 pounds affect the way you live your life?

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* 14. Do you eat sensibly in front of others and splurge alone?

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* 15. Do you give too much time and thought to food?

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* 16. Do you have feelings of guilt after overeating?

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* 17. How conscious are you of what you are eating?

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* 18. Sometimes, when I’m doing everyday activities, I get an urge to eat “out of the blue” (for no apparent reason).

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* 19. I think I enjoy eating a lot more than most other people.

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* 20. Hearing someone describe a great meal makes me really want to have something to eat.

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* 21. It seems like I have food on my mind a lot.

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* 22. It’s very important to me that the foods I eat are as delicious as possible.

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* 23. Before I eat a favorite food my mouth tends to flood with saliva.

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* 24. When I see delicious foods in advertisements or commercials, it makes me want to eat.

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* 25. I feel like food controls me rather than the other way around.

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* 26. Just before I taste a favorite food, I feel intense anticipation.

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* 27. When I eat delicious food I focus a lot on how good it taste.

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* 28. I love the taste of certain foods so much that I can’t avoid eating them even if they’re bad for me.

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* 29. I find myself thinking about food even when I’m not physically hungry

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* 30. When I’m in a situation where delicious foods are present but I have to wait to eat them, it is very difficult for me to wait.

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* 31. I get more pleasure from eating than I do from almost anything else

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* 32. I feel that food is to me like liquor is to an alcoholic.

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* 33. If I see or smell a food I like, I get a powerful urge to have some.

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* 34. When I’m around a fattening food I love, it’s hard to stop myself from at least tasting it.

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* 35. I often think about what foods I might eat later in the day.

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* 36. It’s scary to think of the power that food has over me.

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* 37. When I taste a favorite food, I feel intense pleasure.

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* 38. When I know a delicious food is available, I can’t help myself from thinking about having some.

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* 39. I look forward with enjoyment to things:

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* 40. I get sudden feelings of panic:

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* 41. I feel as if I am slowed down:

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* 42. I can enjoy a good book or radio or TV program

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* 43. I can laugh and see the funny side of things:

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* 44. I have lost interest in my appearance:

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* 45. Worrying thoughts go through my mind:

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* 46. I feel restless as I have to be on the move:

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* 47. I feel cheerful:

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* 48. I can sit at ease and feel relaxed:

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* 49. I still enjoy the things I used to enjoy

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* 50. I get a sort of frightened feeling, as if something awful is about to I get a sort of frightened feeling, as if
something awful is about to happen:

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* 51. I get a sort of frightened feeling like 'butterflies' in the stomach:

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* 52. I feel tense or 'wound up':

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* 53. Do you feel happy in general? Please choose a number: Not at all 0 1 2 3 4 5 6 7 8 9 10 Very

Below is a list of problems and complaints that people sometimes have in response to stressful experiences. Please read each one
carefully, and circle the number that indicates how much you been bothered by that problem in the past month. 1= Not at all
3=Moderately 5=Extremely

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* 54. Repeated, disturbing memories, thoughts, or images of a stressful experience?

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* 55. Feeling very upset when something reminded you of a stressful experience?

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