Eating Habits Survey will Help Us ALL with U.S. Senate Beginning this Fall

EATING HABITS SURVEY

FIRST NAME:_________________MALE:___FEMALE___ STATE:___________ COUNTRY:________________ DATE:____________AGE:____

I HAVE FRIENDS WHO DO BINGE EATING: ( ) YES

NO ( )
IF YES, HOW MANY FRIENDS?____________
I HAVE FRIENDS WHO PURGE AFTER EATING: ( ) YES

NO ( )
IF YES, HOW MANY FRIENDS?____________
HOW OFTEN DO YOUR FRIENDS PURGE? ( ) TIMES A WEEK

I HAVE FRIENDS WHO ARE VERY AFRAID OF GAINING

WEIGHT: ( ) YES NO ( )
I AM DIETING RIGHT NOW: ( ) YES ( ) NO
I SOMETIMES PURGE MYSELF: ( ) YES ( ) NO IF YES, HOW OFTEN_____________
SOMEONE IN MY FAMILY IS ON A DIET RIGHT NOW: ( ) YES ( ) NO
IF YES, WHAT FAMILY MEMBER?_________________
what is your height and weight? height _______weight _____

I WANT TO HEAR YOUR STORY. PLEASE COMPLETE THIS SURVEY BY ANSWERING THESE QUESTIONS IN A BLOG COMMENT AND INCLUDE ANY OTHER INFORMATION YOU WANT TO SHARE ON MY BLOG:

http://www.yourjoyfullife.blogspot.com/
Author Susan Mitchell Collin "The Joyful Life of a Diet Dropout"

Results of this survey will be forwarded to Senator Chris Dodd who is beginning hearings on eating disorders in the U.S. Senate beginning this fall. Thanks for taking the time! Always remember you are beautiful just the way you are!