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What is your current age in years?
15
24
32
41
49
58
66
75
83
92
100
Age
What is your height (please specify if your response is in centimeters, meters, or feet/inches)?
If you don't know, please provide your best estimate.
What is your weight (please specify if your response is in kg's or pounds)?
If you don't know, please provide your best estimate.
What is your sex?
Male
Female
Which Country do you current live in?
What is your ethnic background?
White/Caucasian
African American
Hispanic
Asian
Native American
Pacific Islander
Other (please specify)
Have you ever seen a mental health professional for disordered eating behaviors and/or thoughts?
Yes
No
Are you
currently
seeing a mental health professional for disordered eating behaviors and/or thoughts?
Yes
No
How motivated are you to change your disordered eating behaviors and/or thoughts?
Extremely unmotivated
Extremely motivated
0
5
.
I worry that health professionals would judge me if I revealed my eating disorder behaviors and/or thoughts
Not at all true of me
Very true of me
.
I am ambivalent towards changing my eating disorder behaviors and/or thoughts
Not at all true of me
Very true of me
0
5
.
What are the reason(s) for visiting Break Binge Eating?
Select as many options as you like
To learn more about eating disorders
To get help for my eating disorder behaviors and/or thoughts
To help a loved one with an eating disorder
To find other helpful eating disorder-related resources
Other (please specify)
What are some of the barriers that might prevent or deter you from seeking professional help for your eating behaviors and/or thoughts?
Select as many options as you like
Financial cost
Geographical constraints
Confidentiality/privacy concerns
Stigma associated with seeking help for my problem
I wouldn't know where to seek help from
Other (please specify)
Do you feel that you need professional help for the level of disordered eating behaviors and/or thoughts you're currently experiencing?
Yes
No
I'm not sure
Please rate the extent to which you agree with the following statement.
Please rate the extent to which you agree with the following statement.
Strongly disagree
Disagree
Neither disagree nor agree
Agree
Strongly agree
I am concerned about the level of disordered eating behaviors and/or thoughts I am currently experiencing
Strongly disagree
Disagree
Neither disagree nor agree
Agree
Strongly agree
Question 1-12: Please click the appropriate circle. Remember that the questions only refer to the last
4 weeks
(28 days).
Question 1-12: Please click the appropriate circle. Remember that the questions only refer to the last
4 weeks
(28 days).
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
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)?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
Have you gone for long periods of time (8 waking hours or more) without eating anything at all in order to influence your shape or weight?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
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)?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
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)?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
Have you had a definite desire to have a totally flat stomach?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
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)?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
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)?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
Have you had a definite fear of losing control over eating?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
Have you had a definite fear that you might gain weight?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
Have you felt fat?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
Have you had a strong desire to lose weight?
No days
1-5 days
6-12 days
13-15 days
16-22 days
23-27 days
Every day
Questions 13-18: Please fill in the appropriate number in the boxes on the right. Remember that the questions only refer to the
past four weeks
(28 days).
Over the past four weeks (28 days)...
0
10
20
30
40
50
60
70
80
90
100
Over the past month, how many times have you eaten an unusually large amount of food in one go and at the time feeling that your eating was out of control (binge ate)?
Over the past month, how many times have you felt your eating was out of control when others might not agree the amount of food was unusually large?
Over the past 28 days, how many times have you exercised in a "driven" or "compulsive" way as a means of controlling your weight, shape or amount of fat, or to burn off calories?
Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight?
Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight?
Questions 19-21: Please note that for the next three 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 19-21: Please note that for the next three 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.
No days
1-5 Days
6-12 Days
13-15 days
16-22 days
23-27 days
Every day
Over the past 28 days, on how many days have you eaten in secret (i.e., furtively)? ... Do not count episodes of binge eating
No days
1-5 Days
6-12 Days
13-15 days
16-22 days
23-27 days
Every day
None of the times
A few of the times
Less than half
Half of the times
More than half
Most of the time
Every time
On what proportion of the times that you have eaten have you felt guilty (felt that you've done wrong) because of its effect on your shape or weight? ... Do not count episodes of binge eating
None of the times
A few of the times
Less than half
Half of the times
More than half
Most of the time
Every time
Not at all
.
Slightly
.
Moderately
.
Markedly
Over the past 28 days, how concerned have you been about other people seeing you eat? ... Do not count episodes to binge eating
Not at all
.
Slightly
.
Moderately
.
Markedly
Questions 22-28: Please click the appropriate circle. Remember that the questions only refer to the
past four weeks
(28 days).
Over the past four weeks (28 days)...
Questions 22-28: Please click the appropriate circle. Remember that the questions only refer to the
past four weeks
(28 days).
Over the past four weeks (28 days)...
Not at all
.
Slightly
.
Moderately
.
Markedly
Has your weight influenced how you think about (judge) yourself as a person?
Not at all
.
Slightly
.
Moderately
.
Markedly
Has your shape influenced how you think about (judge) yourself as a person?
Not at all
.
Slightly
.
Moderately
.
Markedly
How much would it have upset you if you had been asked to weigh yourself once a week (no more, or less, often) for the next four weeks?
Not at all
.
Slightly
.
Moderately
.
Markedly
How dissatisfied have you been with your weight?
Not at all
.
Slightly
.
Moderately
.
Markedly
How dissatisfied have you been with your shape?
Not at all
.
Slightly
.
Moderately
.
Markedly
How uncomfortable have you felt seeing your body (for example, seeing your shape in the mirror, in a shop window reflection, while undressing or taking a bath or shower)?
Not at all
.
Slightly
.
Moderately
.
Markedly
How uncomfortable have you felt about others seeing your shape or figure (for example, in communal changing rooms, when swimming, or wearing tight clothes)?
Not at all
.
Slightly
.
Moderately
.
Markedly
Deakin University CRICOS Provider Code 00113B.
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