Age: Sex: Height: feet, inches
Current Weight (lbs.): Highest Weight: Lowest Adult Weight:

Education: If currently enrolled in college/university, are you a:
Freshman Sophomore Junior Senior Grad Student

If not enrolled in school, level of education completed:
Jr. High/Middle School High School College Post College

Ethnic/Racial Group: African American Asian American European American
Hispanic American Indian Other

Do you participate in athletics at any of the following levels:
Intramural Inter-Collegiate Recreational High School Teams

Please check a response for each of the following statements:

Please respond to each of the following questions:
1. Have you gone on eating binges where you feel that you may not be able to stop?
(Eating much more than most people would eat under the circumstances)
No Yes If yes, on average, how many times per month in the last 6 months?
2. Have you ever made yourself sick (vomited) to control your weight or shape?
No Yes If yes, on average, how many times per month in the last 6 months?
3. Have you ever used laxatives, diet pills or diuretics (water pills) to control your weight or shape?
No Yes If yes, on average, how many times per month in the last 6 months?
4. Have you ever been treated for an eating disorder? No Yes If yes, when?
5. Have you recently thought of or attempted suicide? No Yes If yes, when?