Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastDate of Birth *Today's Date *The following questions ask about your eating patterns and behaviors within the last 3 months. For each question, choose the answer that best applies to you. During the last 3 months, did you have any episodes of excessive overeating (i.e., eating significantly more than what most people would eat in a similar period of time)? *YesNoYou answered “NO” to the first question. End of form. Do you feel distressed about your episodes of excessive overeating? *YesNoDuring your episodes of excessive overeating, how often did you feel like you had no control over your eating (e.g., not being able to stop eating, feel compelled to eat, or going back and forth for more food)? *Never or RarelySometimesOftenAlways of of time)? During your episodes of excessive overeating, how often did you continue eating even though you were not hungry? *Never or RarelySometimesOftenAlwaysDuring your episodes of excessive overeating, how often were you embarrassed by how much you ate?Never or RarelySometimesOftenAlwaysDuring your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterward? *Never or RarelySometimesOftenAlwaysDuring the last 3 months, how often did you make yourself vomit as a means to control your weight or shape? *Never or RarelySometimesOftenAlwaysSubmit
