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Your name*

First NameLast Name
Your email*
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How did you first hear about Explore: Freeform?*

Directions: Please complete all questions, choosing NO or 0 for questions that don't apply.

Over the past 3 months...

	0 (Not at all)	1	2 (Slightly)	3	4 (Moderately)	5	6 (Extremely)
Have you felt fat?
Have you had a definite fear that you might gain weight or become fat?
Has your weight or shape influenced how you judge yourself as a person?

During the past 3 months have there been times when you have eaten what other people would regard as an unusually large amount of food (e.g., a pint of ice cream) given the circumstances?*

YesNo
During the times when you ate an unusually large amount of food, did you experience a loss of control (e.g., felt you couldn't stop eating or control what or how much you were eating)?*

YesNo
How many times per month on average over the past 3 months have you eaten an unusually large amount of food and experienced a loss of control?

During episodes of overeating with a loss of control, did you...

	Yes	No
Eat much more rapidly than normal?
Eat until you felt uncomfortably full?
Eat large amounts of food when you didn't feel physically hungry?
Eat alone because you were embarrassed by how much you were eating?
Feel disgusted with yourself, depressed, or very guilty after overeating?
If you have episodes of uncontrollable overeating, does it make you very upset?

In order to prevent weight gain or counteract the effects of eating, how many times per month on average over the past 3 months have you: made yourself vomit?
In order to prevent weight gain or counteract the effects of eating, how many times per month on average over the past 3 months have you: used laxatives or diuretics?
In order to prevent weight gain or counteract the effects of eating, how many times per month on average over the past 3 months have you: fasted (skipped at least 2 meals in a row)?
In order to prevent weight gain or counteract the effects of eating, how many times per month on average over the past 3 months have you: engaged in more intense exercise specifically to counteract the effects of overeating?
How many times per month on average over the past 3 months have you eaten after awakening from sleep or eaten an unusually large amount of food after your evening meal and felt distressed by the night eating?
How much do eating or body image problems impact your relationships with friends and family, work performance, and school performance?

0 (Not at all)12 (Slightly)34 (Moderately)56 (Extremely)
Directions: Please read each of the following items carefully and indicate the statement that best reflects your agreement with the statement.

	Definitely Disagree	Mostly Disagree	Neither Agree Nor Disagree	Mostly Agree	Definitely Agree
It is important for me to look athletic.
I think a lot about looking muscular.
I want my body to look very thin.
I want my body to look like it has little fat.
I think a lot about looking thin.
I spend a lot of time doing things to look more athletic.
I think a lot about looking athletic.
I want my body to look very lean.
I think a lot about having very little body fat.
I spend a lot of time doing things to look more muscular.

Answer the following questions with relevance to your family (include: parents, brothers, sisters, relatives):

	Definitely Disagree	Mostly Disagree	Neither Agree Nor Disagree	Mostly Agree	Definitely Agree
I feel pressure from family members to look thinner.
I feel pressure from family members to improve my appearance.
Family members encourage me to decrease my level of body fat.
Family members encourage me to get in better shape.

Answer the following questions with relevance to your peers (include: close friends, classmates, other social contacts):

	Definitely Disagree	Mostly Disagree	Neither Agree Nor Disagree	Mostly Agree	Definitely Agree
My peers encourage me to get thinner.
I feel pressure from my peers to improve my appearance.
I feel pressure from my peers to look in better shape.
I get pressure from my peers to decrease my level of body fat.

Answer the following questions with relevance to the media (include: television, magazines, the Internet, movies, billboards, and advertisements):

	Definitely Disagree	Mostly Disagree	Neither Agree Nor Disagree	Mostly Agree	Definitely Agree
I feel pressure from the media to look in better shape.
I feel pressure from the media to look thinner.
I feel pressure from the media to improve my appearance.
I feel pressure from the media to decrease my level of body fat.

Directions: Please read each of the following items carefully and indicate the statement that best reflects your agreement with the statement.

How satisfied are you with your...

Directions: Read each item carefully. Using the scale shown below, please take a few moments to reflect on the answer that best describes how you think about yourself right now and what is going on in your life at this moment.

Once you have reflected, please go ahead and answer each item according to the scale written.
If I should find myself in a jam, I could think of many ways to get out of it.

Definitely FalseMostly FalseSomewhat FalseSlightly FalseSlightly TrueSomewhat TrueMostly TrueDefinitely True
At the present time, I am energetically pursuing my goals

Definitely FalseMostly FalseSomewhat FalseSlightly FalseSlightly TrueSomewhat TrueMostly TrueDefinitely True
There are lots of ways around any problem that I am facing now

Definitely FalseMostly FalseSomewhat FalseSlightly FalseSlightly TrueSomewhat TrueMostly TrueDefinitely True
Right now, I see myself as being pretty successful

Definitely FalseMostly FalseSomewhat FalseSlightly FalseSlightly TrueSomewhat TrueMostly TrueDefinitely True
I can think of many ways to reach my current goals

Definitely FalseMostly FalseSomewhat FalseSlightly FalseSlightly TrueSomewhat TrueMostly TrueDefinitely True
At this time, I am meeting the goals that I have set for myself

Definitely FalseMostly FalseSomewhat FalseSlightly FalseSlightly TrueSomewhat TrueMostly TrueDefinitely True

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