Osteopathic Family Medicine, LLC

First name * Last name * Date of birth *

Questions about eating and exercise

Do you often feel that you can?t control what or how much you eat? Do you often eat, within any 2-hour period, what most people would regard as an unusually large amount of food?

If you answered NO to the above questions, please press the submit button below, your questionnaire is complete. Otherwise, please continue.

Has this been as often, on average, as twice a week for the last 3 months?

In the last 3 months have you often done any of the following in order to avoid gaining weight?

Made yourself vomit? Took more than twice the recommended dose of laxatives? Fasted ?? not eaten anything at all for at least 24 hours? Exercised for more than an hour specifically to avoid gaining weight after binge eating?