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Are you a perfectionist, a person who always wants to be in control, an overachiever and/or do you think no matter what you do it is never enough
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O Yes O No O Maybe
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Do you find that you seek or desire acceptance and/or approval from people, and/or that you have a hard time saying “no”?
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O Yes O No O Maybe
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Do you find that you are always questioning your own judgments and/or actions, and/or do you scrutinize yourself over small faults?
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O Yes O No O Maybe
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Do you think you are not good enough, stupid, and/or worthless or that people are always judging you in a negative way?
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O Yes O No O Maybe
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Do you hide your feelings and/or opinions from people for fear of being judged negatively, and/or do you feel like a burden to others with your problems?
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O Yes O No O Maybe
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Within your family and/or circle of friends are you considered “the strong one” who everyone will come to with problems, and/or you never seem to talk much about your own?
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O Yes O No O Maybe
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Do you think life would be better and/or people would like you more if you were thin/thinner?
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O Yes O No O Maybe
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Do you continuously feel that you are overweight even though others have told you that you are not?
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O Yes O No O Maybe
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Do family members and/or friends often express concern for your weight-loss/gain, your appearance, and/or your eating habits?
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O Yes O No O Maybe
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Do you feel as though you have a “conscience” or “voice” that tells you negative things about yourself, convinces you that you do not deserve to eat and/or to be happy, or that tells you that you are or deserve to be fat and ugly?
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O Yes O No O Maybe
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Are you depressed, suicidal, stressed-out, and/or fatigued; and/or do you suffer from anxiety or panic attacks, mood swings, rage and/or insomnia?
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O Yes O No O Maybe
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Do you eat, self-starve, or restrict, binge and/or purge, and/or compulsively exercise when you are feeling lonely, badly about yourself or about a situation, or when you are feeling emotional pressures?
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O Yes O No O Maybe
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While eating, self-starving, or binging and/or purging, do you feel comforted, relieved, liked emotional pressures have been lifted, or like you are in more control?
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O Yes O No O Maybe
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Do you typically feel guilty after a binge, or after any snack or meal, and like you have almost instantly gained weight, like you are a failure, and/or like you have sabotaged yourself?
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O Yes O No O Maybe
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Do you drink a lot of water, tea, or coffee; eat a lot of candy or junk food and/or gum; smoke and/or take caffeine pills as an attempt to control appetite and/or feel energetic?
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O Yes O No O Maybe
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Do you set weight-goals for yourself only to find when you reach it that you want to lose more?
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O Yes O No O Maybe
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Do you do any of the following: hide and/or steal food; use laxatives and/or diet pills; eat and/or exercise secretively; avoid eating in public or around others; wear clothes that hide your weight; and/or make excuses (like “I don’t feel well) to avoid meals?
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O Yes O No O Maybe
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Do you use self-injury (cutting yourself, burning yourself, pulling out your own hair) as a way to cope with things?
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O Yes O No O Maybe
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Are you temperature sensitive (always feel cold or hot) and/or do you get tingling in your extremities (hands and feet)?
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O Yes O No O Maybe
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Are you unrealistically tired relative to the amount of energy expended (ex. Do you feel winded or dizzy after climbing a flight of stairs), and/or do you find yourself often fatigued?
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O Yes O No O Maybe
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Do you suffer any of the following: disruption in menstrual cycle and/or irregularity, infertility, decreased sex drive, irritability; lack of ability to concentrate, blurred vision; kidney and/or urinary tract infections; sore throats, dental problems; stomach cramping, blood in stools or vomit, diarrhea, constipation and/or incontinence (loss of bowel control); insomnia, fatigue, and/or anxiety or depression?
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O Yes O No O Maybe
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