0 : Not at all
1
2
3 : A lot
¹
0
1
2
3
1
Over the past month, to what extent have your eating habits, exercising, or feelings about your eating, shape or weight...
made you feel ashamed of yourself.
2
made you feel guilty.
3
made you feel critical of yourself.
4
made you feel a failure.
5
made you upset.
6
made you worry.
7
interfered with meals with family or friends.
8
made it difficult to eat out with others.
9
interfered with you doing things you used to enjoy.
10
stopped you going out with others.
11
interfered with your relationship with others.
12
made you absent-minded.
13
made you forgetful.
14
affected your ability to make everyday decisions.
15
affected your performance at work (if applicable).
16
made it difficult to concentrate.
The presented answer sheet is not an original form and is not intended for printing or use as a handout.
The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.