Draft Eating Disorder Questionnaire

Consent Information Statement

The current questionnaire examines eating behaviour.
To participate in this questionnaire you are required to have been referred by a health professional or specialist in a clinic. You are required to be over the age of 18 years, or have parental/guardian consent if under 18 years, to complete this questionnaire.

If you choose to participate, you will be required to complete a short questionnaire which should take approximately ** minutes, in which you will provide some general demographic information, respond to various items in reference to eating behaviours, as well as some general questions about yourself.

While some items may seem similar, it is important to respond honestly to all of the questions giving equal attention to each. Try not to spend too much time on any of the items, as your initial response is usually the most accurate.

Your responses to this questionnaire are confidential, and will only bee seen by your clinician. Although unlikely, the questionnaire may raise some concerns for you because of some personal experiences or questions. If you would like to discuss these with your clinician, contact you clinician.

Your participation in this questionnaire is voluntary. You may withdraw your participation at any stage of the questionnaire, by clicking the exit button at the bottom of each page of the questionnaire.

I Consent

Instructions: The following questions are concerned with the past four weeks (28 days) only. Please read each question carefully. Please answer all the questions. Thank you.

Questions 1 to 12: Please select the appropriate number on the right. Remember that the questions only refer to the past four weeks (28 days) only.

On how many of the past 28 days....

	No days	1-5 days	6-12 days	13-15 days	16-22 days	23-27 days	Every day
* 1. Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)?

* 2. Have you gone for long periods of time (8 waking hours or more) without eating anything at all in order to influence your shape and weight?

* 3. Have you tried to exclude from your diet any foods that you like in order to influence your shape or weight (whether or not you have succeeded)?

* 4. Have you tried to follow definite rules regarding your eating (for example, a calorie limit) in order to influence your shape or weight (whether or not you have succeeded)>

* 5. Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight?

* 6. Have you had a definite desire to have a totally flat stomach?

6. Have you had a definite desire to have a totally flat stomach?

7. Has thinking about food, eating or calories made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)?

8. Has thinking about shape or weight made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)?

9. Have you had a definite fear of losing control over eating?

10. Have you had a definite fear that you might gain weight?

11. Have you felt fat?

12. Have you had a strong desire to lose weight?

Instructions: Bul/BED

Questions 19-?: Please circle the appropriate number. Please note that for these questions the term "binge eating" means eating what others would regard as an unusually large amount of food for the circumstances, accompanied by a sense of having lost control over eating.

Questions ?-?: Please select the appropriate number on the right. Remember that the questions only refer to the past four weeks (28 days).

Over the past 28 days.... 0 = Not at all, 2 = Slightly, 4 = Moderately, 6 = Markedly

What is your weight at present? (Please give your best estimate.)

What is your height? (Please give your best estimate.)

What is your weight at present? (Please give your best estimate.)

What is your height? (Please give your best estimate.)