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[x] I’ve consumed alcohol

[] I regularly drink

[] I can’t swallow pills

[] I can swallow numerous pills at a time without water

[x] I have been diagnosed with clinical depression

[x] I shut others out when I’m upset

[] I take anti-depressants

[] I’m anorexic or bulimic or have EDNOS

[x] I’ve slept an entire day when I didn’t need it 

[x] I’ve hurt myself on purpose

[x] I’m addicted to self harm

[x] I’ve woken up crying 

[x] I’ve lost weight 

[x] I’ve gained weight 

[x] 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 

[xxx] I’ve lost weight but gained it back 

[x] My weight affects my mood 

[x] I weigh myself daily 

[x] I am jealous of everyone smaller than me 

[] I thrive on compliments 

[x] I feel bigger than people who are my size 

[] I feel happy when I’m hungry 

[x] I get depressed after I eat 

[x] I’ve skipped a meal 

[x] I’ve thrown food away 

[x] I’ve spit food out 

[x] I’ve fasted 

[] I’ve taken diet pills 

[] I’ve used laxatives 

[x] I’ve purged 

[x] I exercise 

[] I exercise so I can eat 

[] I work out secretly 

[] I work out daily  

[] I’ve fainted from exhaustion 

I’VE DONE: 

[] Weed 

[x] Cigarettes 

[x] Alcohol 

[] Diet pills 

[x] Pain killers 

[] Sleeping pills

[] Anti-depressants 

[ ] Ecstasy 

[ ] LSD 

[ ] Mushrooms 

[] Speed 

[ ] Cocaine 

[] Other

HABITS:

[x] I keep my eating habits a secret 

[] I look at thinspo 

[] I collect thinspo 

[x] I count calories 

[x] I’ve had negative intake days 

[x] I avoid food 

[x] I hate food 

[x] I love food 

[] I want to be this way 

[x] I don’t want to be like this 

[x] I wish I could have more control 

[x] Being thin is my top priority 

[x] I am in treatment