| RPT |
|Eating Disorder Examination Questionnaire (EDE-Q)
| Gender: <.Patient_Gender.>
| 25 How dissatisfied have you been with your weight?
| <*Answer_8730*>
| 26 How dissatisfied have you been with your shape?
| <*Answer_8731*>
| 27 How uncomfortable have you felt seeing your body (for example,
| seeing your shape in the mirror, in a shop window reflection,
| while undressing or taking a bath or shower)?
| <*Answer_8732*>
| 28 How uncomfortable have you felt about others seeing your shape or
| figure (for example, in communal changing rooms, when swimming, or
| <*Answer_7771*>
| wearing tight clothes)?
| <*Answer_8733*>
| What is your weight at present? (Please give your best estimate.)
| <*Answer_8734*>
| What is your height? (Please give your best estimate.)
| <*Answer_8735*>
| If female: Over the past three to four months have you missed any
| menstrual periods?
| <*Answer_8736*>
| If so, how many?
|
| <*Answer_8737*>
| Have you been taking the "pill"?
| <*Answer_8738*>
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
||(c) 2008 Christopher G Fairburn and Sarah Beglin
| Higher scores on the global scale and subscales denote more problematic
| eating behaviors and attitudes. A global score of 4 or greater is
| generally considered clinically significant.
|
|
|Questions and Answers:
|
|
| 1 Have you been deliberately trying to limit the amount of food you
| eat to influence your shape or weight (whether or not you have
| succeeded)?
| <*Answer_8706*>
| 2 Have you gone for long periods of time (8 waking hours or more)
| without eating anything at all in order to influence your shape
| or weight?
| <*Answer_8707*>
| 3 Have you tried to exclude from your diet any foods that you like
| in order to influence your shape or weight (whether or not you have
| Date Given: <.Date_Given.>
| succeeded)?
| <*Answer_8708*>
| 4 Have you tried to follow definite rules regarding your eating (for
| example, a calorie limit) in order to influence your shape or weight
| (whether or not you have succeeded)?
| <*Answer_8709*>
| 5 Have you had a definite desire to have an empty stomach with the aim
| of influencing your shape or weight?
| <*Answer_8710*>
| 6 Have you had a definite desire to have a totally flat stomach?
| Clinician: <.Staff_Ordered_By.>
| <*Answer_8711*>
| 7 Has thinking about food, eating or calories made it very difficult
| to concentrate on things you are interested in (for example, working,
| following a conversation, or reading)?
| <*Answer_8712*>
| 8 Has thinking about shape or weight made it very difficult to
| concentrate on things you are interested in (for example, working,
| following a conversation, or reading)?
| <*Answer_8713*>
| 9 Have you had a definite fear of losing control over eating?
| Location: <.Location.>
| <*Answer_8714*>
| 10 Have you had a definite fear that you might gain weight?
| <*Answer_8715*>
| 11 Have you felt fat?
| <*Answer_8716*>
| 12 Have you had a strong desire to lose weight?
| <*Answer_8717*>
| 13 Over the past 28 days, how many times have you eaten what other
| people would regards as an unusually large amount of food (given
| the circumstances)?
|
| <*Answer_8718*>
| 14 ... On how many of these times did you have a sense of having lost
| control over your eating (at the time you were eating)?
| <*Answer_8719*>
| 15 Over the past 28 days, on how many DAYS have such episodes of
| overeating occurred (i.e. you have eaten an unusually large amount
| of food and have had a sense of loss of control at the time)?
| <*Answer_8720*>
| 16 Over the past 28 days, how many times have you made yourself sick
| (vomit) as a means of controlling your shape or weight?
| Veteran: <.Patient_Name_Last_First.>
| <*Answer_8721*>
| 17 Over the past 28 days, how many times have you taken laxatives as
| a means of controlling your shape or weight?
| <*Answer_8722*>
| 18 Over the past 28 days, how many times have you exercised in a
| driven or compulsive way as a means of controlling your weight,
| shape or amount of fat, or to burn off calories?
| <*Answer_8723*>
| 19 Over the past 28 days, on how many days have you eaten in secret
| (ie, furtively)?
| SSN: <.Patient_SSN.>
| ... Do not count episodes of binge eating
| <*Answer_8724*>
| 20 On what proportion of the times that you have eaten have you felt
| guilty (felt that you ve done wrong) because of its effect on your
| shape or weight?
| ... Do not count episodes of binge eating.
| <*Answer_8725*>
| 21 How concerned have you been about other people seeing you eat?
| ... Do not count episodes of binge eating
| <*Answer_8726*>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| 22 Has your weight influenced how you think about (judge) yourself
| as a person?
| <*Answer_8727*>
| 23 Has your shape influenced how you think about (judge) yourself as
| a person?
| <*Answer_8728*>
| 24 How much would it have upset you if you had been asked to weigh
| yourself once a week (no more, or less, often) for the next four
| weeks?
| <*Answer_8729*>
|
