Rates of Eating Disorders in Southern California
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1. Default Section
1
. Are you a Southern California resident?
Are you a Southern California resident?
Yes
No
2
. Gender
Gender
Male
Female
3
. Age
Age
4
. Do you suffer or have you suffered in the past from some type of eating disorder?
Do you suffer or have you suffered in the past from some type of eating disorder?
Yes
No
Other (please specify)
5
. If you have an eating disorder or have struggled with one in the past, which eating disorder(s) have you dealt with?
If you have an eating disorder or have struggled with one in the past, which eating disorder(s) have you dealt with?
Anorexia Nervosa
Bulimia
Binge Eating disorder/Compulsive Overeating
Eating Disorder NOS (Not Otherwise Specified)
Combination of above (please expand below in "other")
Other (please specify)
6
. Age at onset of Eating Disorder, (your best estimate).
Age at onset of Eating Disorder, (your best estimate).
7
. Have you sought treatment for your disorder? And if so, what kind(s)? Please check all that apply.
Have you sought treatment for your disorder? And if so, what kind(s)? Please check all that apply.
Inpatient hospitalization
Residential Treatment Facility (not in a hospital setting)
Outpatient Individual therapy
Outpatient Family therapy
Intensive Outpatient Program
Support Groups
12-step program
Church Groups
No treatment at all
Other (please specify)
8
. Do you know someone who has suffered from an eating disorder either presently or in the past?
Do you know someone who has suffered from an eating disorder either presently or in the past?
Yes
No
Other (please specify)
9
. What type of eating disorder have they struggled with?
What type of eating disorder have they struggled with?
Anorexia Nervosa
Bulimia
Binge Eating Disorder/Compulsive Overeating
Eating Disorder NOS (Not Otherwise Specified)
Other (please specify)
10
. Where do they live? City and state.
Where do they live? City and state.
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