Clinical Impairment Assessment Questionnaire (CIA 3.0)

Home Questionnaires Clinical Impairment Assessment Questionnaire (CIA 3.0)

Copyright Bohn and Fairburn, 2008

Instructions

Please select the expression 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 (28 days). Thank you.

1. ... made it difficult to concentrate?(Required)
2. ... made you feel critical of yourself?(Required)
3. ... stopped you going out with others?(Required)
4. ... affected your work performance (if applicable)?(Required)
5. ... made you forgetful?(Required)
6. ... affected your ability to make everyday decisions?(Required)
7. ... interfered with meals with family or friends?(Required)
8. ... made you upset?(Required)
9. ... made you feel ashamed of yourself?(Required)
10. ... made it difficult to eat out with others?(Required)
11. ... made you feel guilty?(Required)
12 ... interfered with you doing things you used to enjoy?(Required)
13. ... made you absent-minded?(Required)
14. ... made you feel a failure?(Required)
15. ... interfered with your relationships with others?(Required)
16. ... made you worry(Required)
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