Eating Disorder Survey

Chagrin Counseling Associates & Eating Recovery 29235 Chagrin Blvd., Suite 102, Pepper Pike, Ohio 44122 11740 Clifton Blvd., Suite 202, Lakewood, Ohio 44107 ..Providing innovative techniques to help people meet life's challenges and find peace and balance..

Are You Wondering if You or Someone You Love Has an Eating Disorder

Instructions: Please make a check next to all that apply.

	1.	An intense fear of gaining weight or becoming fat even though you have been told that you are underweight.
	2.	You see your body differently than what other people see.
	3.	You continue to lose weight even though others around you say you need to stop.
	4.	If you are a woman you have missed more than three consecutive menstrual cycles and you are not pregnant.
	5.	Regular (more than 2 times/week for the last 3 months) use of laxatives, diuretics, or enemas.
	6.	Self induce vomiting (more than 2 times/week for the last 3 months).
	7.	Eat more during a short period of time than others would in that same amount of time.
	8.	Feel like you are out of control when you are eating.
	9.	How you feel about yourself changes by how much you weigh or how you feel your body looks that day.
	10.	You regularly restrict what you eat.
	11.	Eat alone because you feel embarrassed.
	12.	Feel guilt after you eat or if you miss a day of exercise.
	13.	Eat large amounts of food when not feeling physically hungry.
	14.	Eat until feeling uncomfortably full.
	15.	Regularly chew and spit out large amounts of food without swallowing.

   *If you are experiencing 3 or more of these symptoms, you may have an eating dis-
     order. It is our recommendation that you contact a mental health professional to
     discuss your concerns.

*American Psychiatric Association (2000). Diagnostic and Statistical Manual Mental
Disorders IV (Text Revision). APA Press: Washington D.C.

**Disclaimer: This tool is not a substitute for psychological testing, psychotherapy
or mental health treatment.**

	For more information* about our services or to schedule an appointment with one of our therapists
	*To reach us by telephone, please call (216) 360-4606
	If you would like to speak with one of our therapists for a free, 15 minute phone* consultation