FBT Survey

The purpose of this survey is to assess the outcomes of your treatment. Please answer all questions honestly. Your
survey will be assigned an identification number, but all information will be kept confidential and used for research
purposes only. Once you have completed your survey, please mail it to the agency or place it in the envelope labeled
FBT Surveys on the front desk. Please contact us if you have any additional questions or concerns.
1.

What is your age?

( ) 12-13 ( ) 14-15 ( ) 16-17

2.

What is your gender?

( ) male ( ) female

3.

Have you reached your ideal body weight?

( ) yes ( ) no ( ) I dont know

4.

For females only: When was the beginning of your last period (approximately)?
( ) within the past 30 days
( ) within the past 3 months
( ) within the past 6 months ( ) within the past 9 months
( ) within the past 12 months ( ) over a year ago ( ) I have never had a monthly period

5.

How many meals per day do you eat on average (including snacks)?
( ) less than 2 ( ) 2-3 ( ) 4-5 ( ) 6-7 ( ) more than 7

6.

How often do you purge or make yourself throw up?

( ) daily basis ( ) weekly basis ( ) monthly basis
( ) less than once a month ( ) never

7.

How often do you binge (overeat)?

( ) daily basis ( ) weekly basis ( ) monthly basis
( ) less than once a month ( ) never

8. Within the past week, how would you rate your dietary restraint?
( ) very low (skipped no meals)
( ) low (skipped 1-2 meals)
( ) moderate (skipped 3-4 meals) ( ) high (skipped 5-6 meals)
( ) very high (skipped 7 or more meals)
9.

Within the past week, how would you rate your shape/figure concern?
( ) very low ( ) low ( ) moderate ( ) high ( ) very high

10. Within the past week, how would you rate your weight concern?
( ) very low ( ) low ( ) moderate ( ) high ( ) very high
11. Within the past week, how would you rate your eating /food concern?
( ) very low ( ) low ( ) moderate ( ) high ( ) very high
12. Within the past week, how would you rate your level of sadness?
( ) very low ( ) low ( ) moderate ( ) high ( ) very high
13. Overall, how would you rate your recovery progress?
( ) very low ( ) low ( ) moderate ( ) high ( ) very high

FBT Survey