This is an archived article.  Although much of the information contained within this article will likely still be relevant and helpful, there may be some content that is outdated or written by a former employee of Center for Change.

By: Unknown

This is the Survey used in the High Schools and was developed by Foundation for Change

Age _____ Sex _____ Height _____ Weight _____

Answer the following questions honestly. Write the number of your answer in the space at the left.
Use the following scale to respond to each question:

1= OFTEN 2= SOMETIMES 3= RARELY 4= NEVER

1. My eating habits are different from my friends.

2. I diet to lose weight.

3. I feel fat.

4. I weigh myself on the scale.

5. I worry about food and what I will or will not eat in a day.

6. I want to eat alone so no one can watch me eat.

7. I compare myself to other people.

8. I eat large amounts of food and I make myself vomit.

9. I use laxatives to control my weight.

10. I believe there is something wrong with how I look.

11. I want to be thinner than my friends.

12. I feel I have to do things perfectly.

13. I play games with food (e.g. lie about what I eat, hide food, cut food in small pieces, etc.).

14. My acceptance from the opposite sex is based on how thin I am.

15. People worry about my eating habits.

16. I dislike myself.

17. I feel I must exercise every day.

18. I miss meals to control my weight.

19. I eat the same foods every day.

20. My greatest fear is becoming fat.

© Copyright – Foundation for Change, 1999