Eating Disorder Survey

A brief screening questionnaire built around five key questions to identify possible signs of an eating disorder.

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Would you (or a loved one) agree that food is the most important aspect of your life?*

Yes No

When others say you are too thin, do you (or a loved one) believe you are fat?*

Yes No

Are you (or a loved one) worried that you have lost control over your eating habits?*

Yes No

Do you (or a loved one) make yourself sick because you feel overly full?*

Yes No

Have you (or a loved one) lost more than 14 pounds in the last three months?*

Yes No

Additional Comments (optional)

Full Name*

First Name

Last Name

Email Address*

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