Clinical Impairment Assessment Questionnaire (CIA)

Please select which best describes how your eating habits, exercising or feelings about your eating, shape or weight have affected your life over the past four weeks. 

Over the past four weeks, to what extent have your eating habits, exercising or your feelings about your eating, shape or weight...

1. ... made it difficult to concentrate (pay attention)?
2. ... made you feel critical of yourself (hard on yourself)?
3. ... stopped you from going out with others?
4. ... affected your work performance (school work)?
5. ... made you forgetful?