Self-Check Questionnaire | The Mirror Project

Name*

Do you feel guilty or ashamed after eating?

Yes

Sometimes

No

Do you avoid certain foods due to fear of weight gain?

Yes

Sometimes

No

Do you frequently think about food or how much you've eaten?

Yes

Sometimes

No

Do you skip meals to “make up” for eating something “bad”?

Yes

Sometimes

No

Do you feel out of control when eating, especially alone?

Yes

Sometimes

No

Do you feel anxious when you look in the mirror?

Yes

Sometimes

No

Do you often compare your body to others?

Yes

Sometimes

No

Do you feel your self-worth is based on your appearance?

Yes

Sometimes

No

Do you avoid events or photos because of how you feel about your body?

Yes

Sometimes

No

Do you feel like your body is never “good enough”?

Yes

Sometimes

No

Have you ever made yourself throw up or over-exercise to lose weight?

Yes

Sometimes

No

Do you feel numb, anxious, or depressed about food or your body?

Yes

Sometimes

No

Do you hide your eating habits from others?

Yes

Sometimes

No

Has your eating/body image affected your ability to focus or enjoy life?

Yes

Sometimes

No

Have you ever wished to disappear because of how you feel about your body?

Yes

Sometimes

No

Would you like someone from The Mirror Project to contact you?*

Yes

No

Email

This is not a diagnosis! If you think something is wrong, take a look at our resource page and reach out for professional help.