CC-COUNSELING 3833 S. Staples Ste N202, Corpus Christi, TX 78411

info@cc-counseling.net www.CC-Counseling.net

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EATING PROFILE QUESTIONNAIRE (EPQ)

From THE 5 REASONS WHY WE OVEREAT: How To Develop a Long-Term Weight Loss Program That's Right for You. By Cynthia G. Last, Ph.D.

Name: _____________________ Read each question and circle the answer that best describes your behavior. Date: ______/______/______

Yes No 1. Do you often eat standing up?

Yes No 2. Is it difficult for you to remember everything you ate today and yesterday?

Yes No 3. Do you often eat between meals?

Yes No 4. Do you tend to finish your food before others?

Yes No 5. Do you often not use plates or utensils when eating?

Yes No 6. Do you frequently do other activities while eating?

TOTALS: Mostly Yes = IMPULSE EATER

Yes No 7. Is quality of food more important than quantity?

Yes No 8. Do you tend to eat slowly?

Yes No 9. Do you enjoy trying different types of food?

Yes No 10. Do you love high-fat or high-sugar foods?

Yes No 11. Do you pass on food that isn’t tasty?

Yes No 12. Is eating one of your greatest pleasures?

TOTALS: Mostly Yes = ENJOYS FOOD

Yes No 13. Are you a nervous or high-strung person?

Yes No 14. Do you often snack when you’re tense or uptight?

Yes No 15. Is it hard for you to resist eating something that is right in front of you?

Yes No 16. Is it difficult for you to relax?

Yes No 17. Is the act of eating often more important than what you are eating?

Yes No 18. Are you a worrier?

TOTALS: Mostly Yes = STRESS EATER

Yes No 19. Is it difficult for you to be assertive?

Yes No 20. Do you have upsetting dreams?

Yes No 21. Do you often eat to avoid thinking about upsetting things?

Yes No 22. Is it sometimes hard for you to identify your feelings?

Yes No 23. Do you have problems that seem impossible to overcome?

Yes No 24. Are you a people-pleaser?

TOTALS: Mostly Yes = AVOIDANCE EATER

Yes No 25. Do you have special feel-good foods?

Yes No 26. Does eating initially give you a lift or a high?

Yes No 27. Do you often feel sad, bored, or down in the dumps?

Yes No 28. Do you often plan out food treats for yourself?

Yes No 29. Are you overly critical of yourself?

Yes No 30. Do you lack energy or enthusiasm?

TOTALS: Mostly Yes = ENERGIZER EATER

.

MAJOR DEPRESSION INVENTORY (MDI)

The Major Depression Inventory (MDI) is a self-report mood questionnaire developed by the World Health

Organization’s Collaborating Center in Mental Health.

The following questions ask how you have been feeling over the last 2 weeks:

All the

time

Most of

the time

Slightly more than

half the time

Slightly less than

half the time

Some of

the time

At no

time

1. Have you felt low in spirits or sad? 5 4 3 2 1 0

2. Have you lost interest in your daily

activities? 5 4 3 2 1 0

3. Have you felt lacking in energy and

strength? 5 4 3 2 1 0

4. Have you felt less self-confident? 5 4 3 2 1 0

5. Have you had a bad conscience or

feelings of guilt? 5 4 3 2 1 0

6. Have you felt that life wasn’t worth

living? 5 4 3 2 1 0

7. Have you had difficulty in

concentrating? 5 4 3 2 1 0

8. Have you felt very restless? 5 4 3 2 1 0

9. Have you felt subdued or slowed down? 5 4 3 2 1 0

10. Have you had trouble sleeping at

night? 5 4 3 2 1 0

11. Have you suffered from reduced

appetite? 5 4 3 2 1 0

12. Have you suffered from increased

appetite? 5 4 3 2 1 0

Totals

20-24 = Mild 25-29 = Moderate 30+ = Severe

Sources

1. P Bech, et al. The sensitivity and specificity of the Major Depression Inventory, using the Present State Examination as the index of diagnostic validity. 66 J Affect Disord 159-164. 2001.

2. LR Olsen, et al. The internal and external validity of the Major Depression Inventory in measuring severity of depressive states. 33 Psychological Medicine 351-356. 2003.

ZUNG SELF-RATING ANXIETY SCALE

For each item below, please check the column which best describes how often you felt or behaved this

way during the past several days.

A little of

the time

Some of

the time

Good part

of the time

Most of

the time

1. I feel more nervous and anxious than usual. 1 2 3 4

2. I feel afraid for no reason at all. 1 2 3 4

3. I get upset easily or feel panicky. 1 2 3 4

4. I feel like I’m falling apart and going to pieces. 1 2 3 4

5. I feel that everything is all right and nothing bad will happen. 4 3 2 1

6. My arms and legs shake and tremble. 1 2 3 4

7. I am bothered by headaches neck and back pain. 1 2 3 4

8. I feel weak and get tired easily. 1 2 3 4

9. I feel calm and can sit still easily. 4 3 2 1

10. I can feel my heart beating fast. 1 2 3 4

11. I am bothered by dizzy spells. 1 2 3 4

12. I have fainting spells or feel like it. 1 2 3 4

13. I can breathe in and out easily. 4 3 2 1

14. I get numbness and tingling in my fingers and toes. 1 2 3 4

15. I am bothered by stomach aches or indigestion. 1 2 3 4

16. I have to empty my bladder often. 1 2 3 4

17. My hands are usually dry and warm. 4 3 2 1

18. My face gets hot and blushes. 1 2 3 4

19. I fall asleep easily and get a good night’s rest. 4 3 2 1

20. I have nightmares. 1 2 3 4

Totals

Grand Total

20-44 Normal Range 45-59 Mild to Moderate Anxiety Levels 60-74 Marked to Severe Anxiety Levels 75-80 Extreme Anxiety Levels

Sources William WK Zung. A Rating Instrument for Anxiety Disorders. 12(6): Psychosomatics 371-379. 1971.

__________________________________________________________________________________________________ Binge Eating Scale

The BES is a 16-item questionnaire assessing the presence of certain binge eating behaviors which may be indicative of

an eating disorder. Below are groups of statements about behavior, thoughts, and emotional states. Please write the

number of the statement in each group that best describes how you feel.

1. I do not think about my weight or size when I’m around other people. 2. I worry about my appearance, but it does not make me unhappy. 3. I think about my appearance or weight and I feel disappointed in myself. 4. I frequently think about my weight and feel great shame and disgust.

1. I have no difficulty eating slowly. 2. I may eat quickly, but I never feel too full. 3. Sometimes after I eat fast I feel too full. 4. Usually I swallow my food almost without chewing, then feel as if I ate too much.

1. I can control my impulses towards food. 2. I think I have less control over food than the average person. 3. I feel totally unable to control my impulses toward food. 4. I feel totally unable to control my relationship with food, and I try desperately to fight my impulses

toward food.

1. I do not have a habit of eating when I am bored. 2. Sometimes I eat when I am bored, but I can often distract myself and not think about food. 3. I often eat when I am bored, but I can sometimes distract myself and not think about food. 4. I have a habit of eating when I am bored and nothing can stop me.

1. Usually when I eat it is because I am hungry. 2. Sometimes I eat on impulse without really being hungry. 3. I often eat to satisfy hunger even when I know I’ve already eaten enough. On these occasions I can’t

even enjoy what I eat. 4. Although I have not physically hungry, I feel the need to put something in my mouth and I feel

satisfied or only when I can fill my mouth (for example with a piece of bread).

After eating too much: 1. I do not feel guilty or regretful at all. 2. I sometimes feel guilty or regretful. 3. I almost always feel a strong sense of guilt or regret.

1. When I’m on a diet, I never completely lose control of food, even in times when I eat too much. 2. When I eat a forbidden food on a diet, I think I’ve failed and eat even more. 3. When I’m on a diet and I eat too much, I think I’ve failed and eat even more. 4. I am always either binge eating or fasting.

1. It is rare that I eat so much that I felt uncomfortably full. 2. About once a month I eat so much that I felt uncomfortably full. 3. There are regular periods during the month when I eat large amounts of food at meals or between

meals. 4. I eat so much that usually, after eating, I feel pretty bad and I have nausea.

1. The amount of calories that I consume is fairly constant over time. 2. Sometimes after I eat too much, I try to consume few calories to make up for the previous meal. 3. I have a habit of eating too much at night. Usually I’m not hungry in the morning and at night I eat

too much. 4. I have periods of about a week in which I imposed starvation diets, following periods of when I ate

too much. My life is made of binges and fasts.

1. I can usually stop eating when I decide I’ve had enough. 2. Sometimes I feel an urge to eat that I cannot control. 3. I often feel impulses to eat so strong that I cannot win, but sometimes I can control myself. 4. I feel totally unable to control my impulses to eat.

1. I have no problems stopping eating when I am full. 2. I can usually stop eating when I feel full, but sometimes I eat so much it feels unpleasant. 3. It is hard for me to stop eating once I start, and I usually end up feeling too full. 4. It is a real problem for me to stop eating and sometimes I vomit because I feel so full.

1. I eat the same around friends and family as I do when I am alone. 2. Sometimes I do not eat what I want around others because I am aware of my problems with food. 3. I often eat little around other people because I feel embarrassed. 4. I’m so ashamed of overeating that I only eat at times when no one sees me. I eat in secret.

1. I eat three meals a day and occasionally a snack. 2. I eat three meals a day and I usually snack as well. 3. I eat many meals, or skip meals regularly. 4. There are times when I seem to eat continuously without regular meals.

1. I don’t think about impulses to eat very much. 2. Sometimes my mind is occupied with thoughts of how to control the urge to eat. 3. I often spend much time thinking about what I ate or how not to eat. 4. My mind is busy most of the time with thoughts about eating. 5. I seem to be constantly fighting not to eat.

1. I don’t think about food any more than most people. 2. I have strong desires for food, but only for short periods. 3. There are some days when I think of nothing but food. 4. Most of my days are filled with thoughts of food. I feel like I live to eat.

1. I usually know if I am hungry or not. I know what portion sizes are appropriate. 2. Sometimes I do not know if I am physically hungry or not. In these moments, I can hardly

understand how much food is appropriate. 3. Even if I knew how many calories I should eat, I would not have a clear idea of what is, for me, a

normal amount of food.

Non-binging; less than 17 Moderate binging; 18-26 Severe binging; 27 and greater

1. J Gormally. The Assessment of Binge Eating Severity Among Obese Persons. 7(1): Addict Behav 47-55. 1982.

CC-COUNSELING 3833 S. Staples., Ste N202, Corpus Christi, TX 78411

Info@cc-counseling.net www.CC-Counseling.net

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