Binge Eating Assessment

Has a healthcare professional told you that you have social anxiety disorder?

In the past three months, did you have eating binges or times when you ate a very large amount of food within a 2-hour period?

During these binges, did you feel that your eating was out of control?

Do you experience fear or anxiety when performing in front of others, such as while speaking in front of a group of people?

Do you experience significant worrying in social situations with people you are not familiar with that is out of proportion to the threat posed?

Feel free to leave this section blank if you did not feel suicidal.

Do social situations almost always cause you to experience fear or anxiety?

Do you have a history of any of the following? (Please select all that apply)

Do you use illicit drugs or marijuana or consume more than 3 drinks of alcohol or 3 beers more than two times a week?

Do you currently take any psychotropic medication like benzodiazepines or SSRIs such as clonazepam (Klonopin), alprazolam (Xanax), or Zoloft?