Eating Disorder Questionnaire

A clinical questionnaire that assesses eating habits and behaviors related to possible eating disorders over the past four weeks.

Use this template

How many times in the last 28 days have you eaten an amount of food that others would consider unusually large?

On how many of these occasions did you feel you had lost control while eating?

How many days in the last 28 days have you had episodes of overeating while feeling out of control?

How many times in the last 28 days have you made yourself vomit to control your weight or shape?

How many times in the last 28 days have you used laxatives to control your weight or shape?

How many times in the last 28 days have you exercised compulsively to control your weight, shape, or burn calories?

What is your current weight? (Please estimate as accurately as possible)

What is your current height? (Please estimate as accurately as possible)

If you are a woman, have you missed any menstrual periods in the last three to four months?

Yes No

How many?

Have you been taking the birth control pill for some time now?

Additional Comments (optional)

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