Do you feel uncomfortable, embarrassed, guilty, or depressed about your physical appearance, your weight or your eating habits? *

Yes

No

Have you ever felt powerless in achieving a healthy weight because you have been unsuccessful in your previous attempts to lose weight permanently? *

Yes

No

Do you resort to compulsive or emotional eating to escape from problems, boredom, to relieve anxiety, or to cope with stress? *

Yes

No

Have you ever tried to stop or limit some aspect of your compulsive-eating behaviors, but have failed in your attempts?

Yes

No

Have you ever said, "This is the last time I'll ever do that!" and yet continued to do it repeatedly in spite of the potential consequences? *

Yes

No

Do you often find yourself preoccupied or obsessed with thoughts about eating or about food? Is it a struggle to stop thinking about food? *

Yes

No

Have your eating behaviors resulted in physical complications such as heart disease, diabetes, high blood pressure, high cholesterol, or other life-threatening illnesses? *

Yes

No

Name *

First Name

Last Name

Phone *

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