For each item, decide if the item is true about you ALWAYS (A), USUALLY (U), OFTEN (O), SOMETIMES (S), RARELY (R), or NEVER (N). Circle the letter that corresponds to your rating.

A

U

O

S

R

N

I eat when I am upset.

A

U

O

S

R

N

I stuff myself with food.

A

U

O

S

R

N

I think about dieting.

A

U

O

S

R

N

I think that my thighs are too large.

A

U

O

S

R

N

I feel extremely guilty after overeating.

A

U

O

S

R

N

I am terrified of gaining weight.

A

U

O

S

R

N

I get confused as to whether or not I am hungry.

A

U

O

S

R

N

I have the thought of trying to vomit in order to lose weight.

A

U

O

S

R

N

I think my buttocks are too large.

A

U

O

S

R

N

I eat or drink in secrecy.

(Information from: Clausen et al., 2011; Garner, 2005; Garner, Olmsted, & Polivy, 1991, 1984.)