Village Family Clinic & Wellness Center

*Please only complete this form if you are being assessed for binge-eating disorder*

Name: * Date *

1. During the last 3 months, did you have any episodes of excessive overeating (i.e., eating signicantly more than what most people would eat in a similar period of time)?

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2. Do you feel distressed about your episodes of excessive overeating?

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3. During 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)?

4. During your episodes of excessive overeating, how often did you continue eating even though you were not hungry?

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5. During your episodes of excessive overeating, how often were you embarrassed by how much you ate?

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6. During your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterward?

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7. During the last 3 months, how often did you make yourself vomit as a means to control your weight or shape?

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