Age:
Height:
Weight:
Dress Size:
Highest Weight:
Lowest Weight:
Goal Weight:
Favorite Diet Food:
Favorite Binge Food:
Favorite Exercise:
Favorite Thinspo:
Where Do You Slip Up:
When Did It Start?:
Hating your body:
Restricting/counting:
Does Anyone Know:
You Want Help:
How Many Calories Do You Consume A Day:
What Do You See When You Look In The Mirror?
Are You In A Relationship:
Are You Depressed:
Ever Tried To Commit Suicide:
Ever Been To A Psychologist:
I AM -
[] anorexic
[] ednos
[] bulimic
[] living off diet pills
[] hungry
[] thirsty
[] drinking something
[] Under 100lbs
[] starving yourself
[] participating in a fast
PEOPLE -
[] ask if I’m anorexic/bulimic
[] call me fat
[] say I’m skinny
[] say I’m ugly
[] say I’m pretty
[] spread rumors about me
[] force me to eat
[] say I eat too much
[] wish I’d eat more
[] don’t know I’m anorexic/bulimic/ednos
I WISH -
[] I was THIN
[] I had a better body
[] I didn’t have to eat
[] I could control myself
[] I was under 100lbs
[] I could avoid food
[] I could hide what I am
[] I wasn’t fat
[] I was pretty
[] I could stop being ana/mia then maybe i would be a little more normal
I LOVE -
[] feeling hungry
[] seeing a difference when fasting
[] shaking
[] being weak
[] losing weight
[] being anorexic/bulimic/ednos
[] green tea
[] diet pills
[] being able to turn down food
[] feeling good about myself
APPEARANCE -
[] I am shorter than 5’4.
[] I think I’m ugly sometimes.
[] I have many scars.
[] I tan easily.
[] I wish my hair was a different color.
[] I have friends who have never seen my natural hair color.
[] I have a tattoo.
[] I am self-conscious about my appearance.
[] I have/had braces.
[] I wear glasses….contacts.
[] I would get plastic surgery if it were 100% safe, free of cost, and scar-free.
[] I’ve been told I’m attractive by a complete stranger
[] I have more than 2 piercings.
[] I have piercings in places besides my ears.
[] I have freckles
FAMILY -
[] I’ve sworn at my parents.
[] I’ve run away from home
[] I’ve been kicked out of the house.
[] My biological parents are together.
[] I have a sibling less than one year old.
[] I want to have kids someday.
[] I’ve had children.
[] I’ve lost a child.
EMBARRASSMENT
[] I’ve slipped out a “lol” in a spoken conversation.
[] Disney movies still make me cry.
[] I’ve peed from laughing.
[] I’ve snorted while laughing.
[] I’ve laughed so hard I’ve cried.
[] I’ve glued my hand to something
[] I’ve laughed till some kind of beverage came out of my nose.
[] I’ve had my trousers rip in public.
RELATIONSHIPS -
[] I’m single
[] I’m in a relationship.
[] I’m engaged.
[] I’m married.
[] I’ve gone on a blind date.
[] I’ve been the dumpee more than the dumper.
[] I miss someone right now.
[] I have a fear of abandonment.
[] I’ve cheated in a relationship.
[] I’ve gotten divorced
[] I’ve had feelings for someone who didn’t have them back.
[] I’ve told someone I loved them when I didn’t.
[] I’ve told someone I didn’t love them when I did.
[] I’ve kept something from a past relationship.
SEXUALITY -
[] I’ve had a crush on someone of the same sex.
[] I’ve had a crush on a teacher.
[] I am a cuddler.
[] I’ve been kissed in the rain.
[] I’ve hugged a stranger.
[] I have kissed a stranger.
HONESTY -
[] I’ve done something I promised someone else I wouldn’t
[] I’ve done something I promised myself I wouldn’t.
[] I’ve snuck out of my house.
[] I have lied to my parents about where I am.
[] I am keeping a secret from the world.
[] I’ve cheated while playing a game.
[] I’ve cheated on a test.
[] I’ve been suspended from school.
BAD TIMES -
[] I’ve consumed alcohol.
[] I regularly drink.
[] I can’t swallow pills.
[] I can swallow about 5 pills at a time no problem
[] I have been diagnosed with clinical depression at some point.
[] I shut others out when I’m upset.
[] I take anti-depressants.
[] I’m anorexic or bulimic or have EDNOS.
[] I’ve slept an entire day when I didn’t need it.
[] I’ve hurt myself on purpose.
[] I’m addicted to self harm.
[] I’ve woken up crying
[] I’ve lost weight
[] I’ve gained weight
[] My weight holds me back
[] Weight consumes me.
[] I’m at my thinnest
[] I’m at my biggest
[] I’ve lost weight and kept it off
[] I’ve lost weight but gained it back
[] My weight affects my mood
[] I weigh myself daily
[] I am jealous of everyone smaller than me
[] I thrive on compliments
[] I feel bigger than people who are my size
[] I feel happy when I’m hungry
[] I get depressed after I eat
[] I’ve skipped a meal
[] I’ve thrown food away
[] I’ve spit food out
[] I’ve fasted
[] I’ve taken diet pills
[]I’ve used laxatives
[] I’ve purged
[] I exercise
[] I exercise so I can eat
[] I work out secretly
[] I work out daily
[] I exercise to counteract eating
[] I’ve fainted from exhaustion
I’VE DONE -
[] Weed
[] Cigarettes
[] Alcohol
[] Diet pills
[] Pain killers
[] Anti-depressants
[] Ecstasy
[] LSD
[] Speed
[] Cocaine
[] Other
[] I keep my eating habits a secret
[] I have a diet blog
[] I look at thinspo
[] I collect thinspo
[] I’m doing this for me
[] I’m doing this for someone
[] I’m doing this to prove myself
