How Do These Statements Pertain To You?  |  |  |  |  |  |  |
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1. I feel comfortable with my body the way it is. |  | | | | | |
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2. I find myself preoccupied with food thoughts or diet thoughts. |  | | | | | |
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3. When I eat I feel out-of-control and distressed. |  | | | | | |
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4. I use food (and thinking about food) to avoid uncomfortable feelings (i.e., I eat when I feel lonely, or depressed, or nervous, or bored). |  | | | | | |
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5. I eat at the same pace as most people. |  | | | | | |
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6. I am preoccupied with a desire to be thinner. |  | | | | | |
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7. In an effort to prevent weight gain, I vomit, or I use laxatives, or I exercise excessively, or I fast (no food for one day or more). |  | | | | | |
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8. I have missed work, school or social events because of my weight or eating habits. |  | | | | | |
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9. I sneak food because I am embarrassed about how much (or what) I eat. |  | | | | | |
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10. I have stolen food, laxatives or diet pills from other people or from a store. |  | | | | | |
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11. I feel guilty after I eat. |  | | | | | |
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12. I eat until I am uncomfortably full. |  | | | | | |
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13. If I weigh myself and I see that my weight is up, that can affect my mood all day long. |  | | | | | |
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14. I believe, “If I could just lose weight, I could be happy”. |  | | | | | |
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15. Have you ever been diagnosed by a therapist or a doctor as having an eating disorder, or depression, or anxiety, or an obsessive compulsive disorder, or alcohol or drug addiction? |  | |
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16. Do you feel like you are currently struggling with an eating disorder, or depression, or anxiety, or an obsessive compulsive disorder, or alcohol or drug addiction? |  | |
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