Freeform by Equip, A Virtual Body Empowerment Program

Thank you for your interest in Equip Freeform!

Please fill out the following survey to begin signing up for an upcoming Freeform body image group. If you have any questions, please email freeform@equip.health.
Your name:*

First NameLast Name
Preferred name:
Pronouns:
Phone Number
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Email:*

Confirmation Emailexample@example.com

Consent to Record
Consent to Record

Previous research has actually shown a higher impact of the group when the sessions were recorded and we also want to continually adapt and improve the program. We currently record all Freeform groups.

If you are under 18, please have a parent or guardian complete the following section. (18+ can complete this section on their own)
Do you consent to record the Freeform Group?*

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During the times when you at an unusually large amount of food, did you experience a loss of control (e.g., felt you couldn't stop eating or control what or how much you were eating)?*

YesNo

	Definitely Disagree	Mostly Disagree	Neither Agree Nor Disagree	Mostly Agree	Definitely Agree
It is important for me to look athletic.
I think a lot about looking muscular.
I want my body to look very thin.
I want my body to look like it has a little fat.
I think a lot about looking thin.
I spend a lot of time doing things to look more athletic.
I think a lot about looking athletic.
I want my body to look very lean.
I think a lot about having very little body fat.
I spend a lot of time doing things to look more muscular.

	Definitely Disagree	Mostly Disagree	Neither Agree Nor Disagree	Mostly Agree	Definitely Agree
I feel pressure from family members to look thinner.
I feel pressure from family members to improve my appearance.
Family members encourage me to decrease my level of body fat.
Family members encourage me to get in better shape.

	Definitely Disagree	Mostly Disagree	Neither Agree Nor Disagree	Mostly Agree	Definitely Agree
My peers encourage me to get thinner.
I feel pressure from my peers to improve my appearance.
I feel pressure from my peers to look in better shape.
I get pressure from my peers to decrease my level of body fat.

	Definitely Disagree	Mostly Disagree	Neither Agree Nor Disagree	Mostly Agree	Definitely Agree
I feel pressure from the media to look in better shape.
I feel pressure from the media to look thinner.
I feel pressure from the media to improve my appearance.
I feel pressure from the media to decrease my level of body fat.

	0 (Not at all)	1	2 (Slightly)	3	4 (Moderately)	5	6 (Extremely)
Have you felt fat?
Have you had a definite fear that you might gain weight or become fat?
Has your weight or shape influenced how you judge yourself as a person?

	Yes	No
Eat much more rapidly than normal?
Eat until you felt uncomfortably full?
Eat large amounts of food when you didn't feel physically hungry?
Eat alone because you were embarrassed by how much you were eating?
Feel disgusted with yourself, depressed, or very guilty after overeating?
If you have episodes of uncontrollable overeating, does it make you very upset?

	0	1	2	3	4	5	6	7	8	9	10	11	12+
Made yourself vomit?
Used laxatives or diuretics?
Fasted (skipped at least 2 meals in a row)?
Engaged in more intense exercise specifically to counteract the effects of overeating

Thank you for your interest in Equip Freeform!