Below are
just some
of the challenges facing those with food, weight, body image and exercise issues. Circle all that you struggle with
or are questioning. Please print out this form and bring to our first session.
2. Restricting and self starvation are obvious to me and others.
3. Bingeing and/or purging are obvious to me and others.
4. I obsess about my weight and complain about it even though family and friends tell me that I am average or thin.
5. I must exercise, frequently and intensely, no matter the weather or even if I'm tired, sick or injured.
6. When I'm eating I'm afraid of losing control, of not being able to stop eating.
7. I'm always going on a diet and trying the latest popular diets yet I end up falling off and bingeing.
8. At least once a day, even multiple times a day, I get on the scale; the number effects my mood and my food for the whole day.
9. My sense of myself is all about my appearance.
10. Frequently I am out of breath after even light activities and don't get around as much because of my obesity.
11. Whenever I eat I feel I have to "pay for eating" by exercising, either afterwards or beforehand.
12. I try to hide my body or weight loss by dressing in big, baggy clothes or wearing layers.
13. I hide food in strange places to avoid eating.
14. I hide food in strange places to eat later.
15. Media images have a major influence on how I feel about myself.
16. My weight is the cause of my personal/professional problems.
17. I know the calorie and fat gram count of every food.
18. When I'm around others I can't eat because of my fears of eating in front of people.
19. No matter what my natural size and shape I always want to look like someone else who is thinner.
20. Habitually when I eat with others I have food rituals such as moving food around the plate or cutting it into small pieces so people think I'm eating.
21. I have recently had a quick, major loss of weight.
22. I am always comparing my appearance to friends, strangers and celebrities and I never win that comparison.
23. My menstrual cycle is irregular or has stopped altogether.
24. After eating I always feel guilty and hate myself.
25. Often I will secretly chew and spit out food without swallowing.
26. In order to be left alone to binge and purge, or not eat, I will isolate from family and friends, cancel or not make social plans.
27. Food scares me.
28. My primary goal in life is about size/appearance rather than health or other accomplishments.
29. I keep records about food and/or behaviors (such as calorie/fat gram counts, exercise, etc.) to try to manage my weight.
30. The doctor tells me that my high blood pressure/high cholesterol/shortness of breath is due to my obesity.
31. I have frequent dizziness and headaches.
32. Often I have sore throats and/or swollen glands, bloodshot eyes, light bruising under the eyes and on the cheeks.
33. All the time I feel worthless, stupid and fat, but especially after eating.
34. If I don't get to exercise my anxiety and/or depression worsens.
35. Even though I've been on a lot of diets my weight ultimately just goes up and up.
36. My sleeping habits are poor and I often suffer from insomnia.
37. Frequently I am depressed and tired and/or have mood swings.
38. I am vague or secretive to others about my eating habits.
39. Thoughts of food, weight and cooking preoccupy my thinking.
40. Even though Ipecac syrup can cause sudden death I continue to use it and/or I use diet pills/laxatives/enemas to try to control my weight.
1. My life is "on hold" until I lose weight.
2. Restricting and self starvation are obvious to me and others.
3. Bingeing and/or purging are obvious to me and others.
4. I obsess about my weight and complain about it even though family and friends tell me that I am average or thin.
5. I must exercise, frequently and intensely, no matter the weather or even if I'm tired, sick or injured.
6. When I'm eating I'm afraid of losing control, of not being able to stop eating.
7. I'm always going on a diet and trying the latest popular diets yet I end up falling off and bingeing.
8. At least once a day, even multiple times a day, I get on the scale; the number effects my mood and my food for the whole day.
9. My sense of myself is all about my appearance.
10. Frequently I am out of breath after even light activities and don't get around as much because of my obesity.
11. Whenever I eat I feel I have to "pay for eating" by exercising, either afterwards or beforehand.
12. I try to hide my body or weight loss by dressing in big, baggy clothes or wearing layers.
13. I hide food in strange places to avoid eating.
14. I hide food in strange places to eat later.
15. Media images have a major influence on how I feel about myself.
16. My weight is the cause of my personal/professional problems.
17. I know the calorie and fat gram count of every food.
18. When I'm around others I can't eat because of my fears of eating in front of people.
19. No matter what my natural size and shape I always want to look like someone else who is thinner.
20. Habitually when I eat with others I have food rituals such as moving food around the plate or cutting it into small pieces so people think I'm eating.
21. I have recently had a quick, major loss of weight.
22. I am always comparing my appearance to friends, strangers and celebrities and I never win that comparison.
23. My menstrual cycle is irregular or has stopped altogether.
24. After eating I always feel guilty and hate myself.
25. Often I will secretly chew and spit out food without swallowing.
26. In order to be left alone to binge and purge, or not eat, I will isolate from family and friends, cancel or not make social plans.
27. Food scares me.
28. My primary goal in life is about size/appearance rather than health or other accomplishments.
29. I keep records about food and/or behaviors (such as calorie/fat gram counts, exercise, etc.) to try to manage my weight.
30. The doctor tells me that my high blood pressure/high cholesterol/shortness of breath is due to my obesity.
31. I have frequent dizziness and headaches.
32. Often I have sore throats and/or swollen glands, bloodshot eyes, light bruising under the eyes and on the cheeks.
33. All the time I feel worthless, stupid and fat, but especially after eating.
34. If I don't get to exercise my anxiety and/or depression worsens.
35. Even though I've been on a lot of diets my weight ultimately just goes up and up.
36. My sleeping habits are poor and I often suffer from insomnia.
37. Frequently I am depressed and tired and/or have mood swings.
38. I am vague or secretive to others about my eating habits.
39. Thoughts of food, weight and cooking preoccupy my thinking.
40. Even though Ipecac syrup can cause sudden death I continue to use it and/or I use diet pills/laxatives/enemas to try to control my weight.
