Eating disorders

How do you lose weight ?

Please select all that apply.

• I starve myself
• I take laxative
• I follow an "unhealthy" diet
• I purge myself
• I follow a "healthy" diet
• I fast
• I cut down on calories
• I exercice
• Other

How old are you ?

• 12 - 13 years old
• 14 - 15 years old
• 16 - 17 years old
• 18 - 19 years old
• + 20 years old

What part of your body do you hate the most ?

• Face
• Arms
• Chest
• Stomach
• Waist
• Hips
• Thights
• Legs
• Other
• None

What is your calorie intake ?

• - 200 cal
• 201 - 300 cal
• 301 - 400 cal
• 401 - 500 cal
• 601 - 700 cal
• 701 - 800 cal
• 801 - 900 cal
• 901 +

Do you want to recover from your ED ?

• Yes, I really want to
• Yes, I've alreday tried
• Maybe
• Maybe when I would have reach my goal weight
• No, but I've already tried
• No, never
• I don't have an ED

What is your "daily diet" ?

Please select all that apply.

• Omnivore
• Vegetarian
• Vegetarian but I eat fish
• Vegan
• Vegan but I take milk
• Vegan but I take eggs
• I'm allergic to some foods (Milk, eggs, gluten ...)

Do you tell your problems to someone ?

Please select all that apply.

• Yes, to my best friend(s)
• Yes, to close friend(s)
• Yes, to my parent(s)
• Yes, to my doctor
• No, but I want to
• No, and I never want to
• I don't have any problem

Do you skip meals ?

• Yes, mostly the breakfast
• Yes, mostly the lunch
• Yes, mostly the dinner
• Yes, often two meals
• Yes, often three meals
• I don't eat every day
• Sometimes one or two meals
• No, never

How much did you lose weight since you start/try to lose ?

• I lost nothing
• My weight fluctuates a lot
• - 1kg ( - 2lbs )
• 1kg - 2kg ( 2lbs - 4.5lbs )
• 2kg - 4kg ( 4.5lbs - 9lbs )
• 4kg - 6kg ( 9lbs - 13lbs )
• 6kg - 8kg ( 13lbs - 17.5lbs )
• 8kg - 10kg ( 17.5 lbs - 22lbs )
• 10kg - 12kg ( 22lbs - 26.5 lbs )
• + 12kg ( + 26.5 lbs )

Does someone has already criticized about how you are ?

Please select all that apply.

• Yes, about my weight
• Yes, about how I dress myself
• Yes, about my face
• Yes, about my hair
• Yes (Other)
• Maybe
• No

Do you think about death ?

• Yes, I hope my ED will kill me
• Yes, but I hope my ED won't kill me
• Yes, I want to kill myself
• Yes, but I don't want to die now
• No, death is one of my fear
• No, never

Do you think you will stop losing when you will reach your goal ?

• Yes, I'm sure
• Yes, I've already reach my goal and I stopped to lose weight
• Maybe, it will depend on how I look
• Maybe, I don't know if I could stop
• No, I'm sure that I would like to continue
• No, I've already reach my goal and I'm still losing weight
• I don't have a goal weight

Do you have any other psychological issue(s) ?

Please select all that apply.

• Depression
• Bipolar
• Bordeline
• Anxiety
• Paranoia
• Obsessive-Compulsive Disorder (OCD)
• Other
• None

What eating disorder do you have ?

• Anorexia nervosa
• Bulimia nervosa
• EDNOS
• Other
• None

Do you think you are beautiful ?

• Yes, I feel beautiful
• Yes, and losing weight will makes me more beautiful
• I don't really judge myself about it
• I'm not beautiful and I'm not ugly
• No, I think I'm ugly but people say that I'm not
• No, I'm sure I'm ugly