5 6 7 8 9 10 11 12 Questions 13 to 18: Please write 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): 13 Over the past 28 days, how many times have you eaten what other people would regard as an unusually large amount of food (given the circumstances)? 14 On how many of these times did you have a sense of having lost control over your eating (at the time you were eating)? 15 Over the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time)? 16 Over the past 28 days, how many have you made yourself sick (vomit) as a means of controlling your shape or weight? 17 Over the past 28 days, how many have you taken laxatives as a means of controlling your shape or weight? 18 Over the past 28 days, how many have you exercised in a or ‘driven’ ‘compulsive’ way as a means of controlling your weight, shape or amount of fat, or to burn off calories? Questions 19 to 21: Please circle or mark the appropriate number.
5 6 7 8 9 10 11 12 Questions 13 to 18: Please write 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): 13 Over the past 28 days, how many times have you eaten what other people would regard as an unusually large amount of food (given the circumstances)? 14 On how many of these times did you have a sense of having lost control over your eating (at the time you were eating)? 15 Over the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time)? 16 Over the past 28 days, how many have you made yourself sick (vomit) as a means of controlling your shape or weight? 17 Over the past 28 days, how many have you taken laxatives as a means of controlling your shape or weight? 18 Over the past 28 days, how many 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? Questions 19 to 21: Please circle or mark the appropriate number.
community-eating-disorders-service-referral-form-final-300616.docx