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Q1: How often do you binge eat/eat compulsively/overeat?
NeverOccasionallySeveral times a weekEvery day
Q2: How long have you had a problem with food?
Q3: What time of day do you eat the most?
MorningAfternoonEveningIt can be at any time of day
Q4: What have you tried up to this point to deal with this problem? How successful were these strategies?
Q5: Tell me what triggered your last overeating episode (An argument? Stress? Boredom? Be as specific as possible)
Q6: What sort of food did you eat on that occasion?
Q7: How did you feel afterwards?
Q8: How important is secrecy for you when you overeat?
Not importantQuite importantEssentialIt depends
Q9: How well are you able to resist your cravings?
I have a range of strategiesIt dependsI can sometimes resist cravingsI can never resist them - they overwhelm me
Q10: What support do you have to help you with your eating and/or weight problems? (people, websites, books etc)
Q11: What do you normally eat for breakfast?
Q12: If you answered 'other', please describe what you normally eat for breakfast
Q13: If you could magically make your eating problems disappear, how would your life improve? How would you be different?
Q14: Is there any additional information you want to include?