1. What is your age? Under 18 Years Old 18 to 24 Years Old 25 to 30 Years Old 31 to 40 Years Old 41 to 50 Years Old 51 to 60 Years Old Over 60 Years Old 2. What is your gender? Male Female 3. What is your current weight? < 90 pounds 90 - 100 pounds 100 - 110 pounds 110 - 120 pounds 120 - 140 pounds 140 + pounds 4. What is your ideal weight? > 80 pounds 80 - 90 pounds 90 - 100 pounds 100 - 120 120 - 140 140 + 5. How many calories do you typically eat in an average day? (If you're not sure, add up the calories eaten in a week and divide by 7) 300 or less 300 - 500 500 - 700 700 - 1000 1000 - 1,500 1,500 + 6. Have you ever fasted? If so, what was your longest successful fast? I've never tried fasting. < 24 hours 24 hours - 2 days 3 - 5 days 6 - 7 days Longer than a week 7. How much weight have you lost since your highest recent weight? I'm at my high weight. :( 5 pounds or less 5 - 10 pounds 10 - 20 pounds 20 - 30 pounds 30 + pounds 8. What do others say about your body? Everyone tells me I need to lose weight. A couple people have said I should diet. No one has said anything about my body. People are generally complimentary of my body. A couple of people have said I should gain weight. Everyone tells me I need to gain weight. 9. Choose which menu reflects what you eat at an average meal. Lettuce leaf, ice water & a diet coke (minimalist, nothing if possible) Cottage cheese or yogurt, fruit, salad (healthy and nonfat) 1/2 a sandwich, or 1/4 of a regular meal (normal food, just reduced portions) Mini chocolate bars, M&Ms, a pretzel, popcorn (snack foods, maybe no meals at all just snacks) Baked chicken, a potato, some green beans and milk (healthy, typical diet) Cheeseburger, french fries, cokes (fast food or high-cal eating) 10. Do you ever binge/purge? If so, how often? Never! Tried it once or twice but it's not for me. Only in emergencies, less than once a month. A couple times a month. At least weekly. Many times a week, or daily. 11. Do you ever lie or avoid other people in order to skip meals without getting caught? No, I have never wanted to skip a meal. No. I rarely skip meals, so this doesn't apply to me. I've had to do this a couple times to avoid meals. I've had to do this often to avoid meals. I skip meals occasionally, but I don't need to lie because no one stops me. I skip meals all the time, but I don't need to lie because no one stops me. 12. Have you ever taken over-the-counter medicine to reduce your appetite or cravings, or to burn fat/raise metabolism? No, and I'd never want to. No, but I've been considering it. No. I've wanted to, but because of legal restrictions such as age or interaction with my other meds I can't. Yes, I've used them before but have since quit. Yes, I currently use them occasionally. Yes, I currently use them often or daily. 13. Have you ever been diagnosed with an eating disorder? Yes, I have been diagnosed with anorexia or bulimia. Yes, I have been diagnosed with a different eating disorder such as COE. I am in the process of seeking a diagnosis. I've never been diagnosed by a professional but friends/family think I have an eating disorder. I've never been diagnosed by a professional, but I think I have an eating disorder. No, I have not been diagnosed and do not have an eating disorder. 14. Have you ever participated in eating disorders therapy or recovery? Yes, and it was voluntary. Yes, and it was at the urging of doctors or family members. I haven't yet but probably will soon. I haven't yet, but I am considering it. I haven't yet but it's possible I may someday. I haven't yet, and don't think I ever will. 15. Do YOU consider yourself eating disordered? Yes, absolutely! Probably, but I'm not entirely sure. Maybe... Probably not. Definitely not!