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, 1999Share