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Wayne State College
Counseling Center
Student Center, Rm. 103
1111 Main St.
Wayne, NE 68787

Phone: 402.375.7321
Fax: 402.375.7058

_____1.

I have eating habits that differ from those of my family and friends.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____2.

I find myself panicking if I cannot exercise as I planned, because I am afraid that I will gain weight if I don't.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____3.

My friends tell me that I am thin, but I don't believe them because I feel fat.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____4.

(Females Only) My menstrual period has stopped or become irregular due to no known medical reasons.
| 1 = True  |  2 = False |

_____5.

I have become obsessed with food to the point that I cannot go through a day without worrying about what I will or will not eat.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____6.

I have lost more than 15% of what is considered to be a healthy weight for my height (e.g., female, 5'4" tall loses 20 pounds when a healthy weight is approximately 122 pounds).
| 1 = True  |  2 = False |

_____7.

I would panic if I got on the scale tomorrow and found that I had gained two pounds.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____8.

I find that I prefer to eat alone or when I am sure that no one will see me, and thus make excuses so that I can eat less and less often with friends or family.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____9.

I find myself going on uncontrollable eating binges during which I consume large amounts of food to the point that I feel sick and make myself vomit.
| 1 = Never  |  2 = Less than 1 time/week  |  3 = 1-6 times/week  |  4 = 1 or more times/day |

_____10.

(NOTE: Answer only if your answer to #9 is "1;" otherwise leave blank.) I find myself compulsively eating more than I want to while feeling out of control and/or unaware of what I am doing.
| 1 = Never  |  2 = Less than 1 time/week  |  3 = 1-6 times/week  |  4 = 1 or more times/day |

_____11.

I use laxatives or diuretics as a means of weight control.
| 1 = Never  |  2 = Less than 1 time/week  |  3 = 1-6 times/week  |  4 = 1 or more times/day |

_____12.

I find myself playing games with food (e.g. cutting it up in tiny pieces, hiding food so people will think I ate it, chewing it and spitting it out without swallowing it, keeping hidden stashes of food) and/or I have determined that there are "safe" foods that are okay for me to eat and "bad" foods that are not.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____13.

People around me have become very interested in what I eat and I find myself getting angry at them for pushing me to eat more.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____14.

I have felt more depressed and irritable recently than is typical for me and/or have been spending an increasing amount of time alone.
| 1 = True  |  2 = False |

_____15.

I keep a lot of my fears about food and eating to myself because I am afraid no one would understand.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____16.

I enjoy making gourmet and/or high calorie foods for others as long as I don't have to eat any myself.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____17.

The most powerful fear in my life is the fear of gaining weight or becoming fat.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____18.

I exercise a lot (more than 4 times per week and/or more than 4 hours per week) as a means of weight control.
| 1 = True  |  2 = False |

_____19.

I find myself totally absorbed when reading books or magazines about dieting, exercising, fitness, or calorie counting to the point that I can spend hours studying them.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____20.

I tend to be a perfectionist and am not satisfied with myself unless I do things perfectly.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____21.

I go through long periods of time without eating (fasting) or eating very little as a means of weight control.

| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

_____22.

It is important for me to try to be thinner than all my friends.
| 1 = Often  |  2 = Sometimes  |  3 = Rarely  |  4 = Never |

38 or less

Strong tendencies toward anorexia nervosa

39-50

Strong tendencies toward bulimia nervosa

50-60

Weight conscious. May or may not have tendencies toward an eating disorder. Not likely to have anorexia or bulimia nervosa. May have tendencies toward compulsive overeating, obesity, or binge-eating disorder.

Over 60

Extremely unlikely to have anorexia nervosa or bulimia nervosa. However, scoring over 60 does not rule out tendencies toward compulsive eating, binge eating disorder, or obesity.

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