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1 If you are seeking treatment for an eating disorder, please complete all seven (7) pages. If you are seeking treatment for something other than an eating disorder, you need only print and complete the first five (5) pages. All new adult patients must also complete the Adult Treatment Agreement. If the patient is a Minor, do NOT use this packet. Instead, complete the three Minor forms: Minor Treatment Agreement Minor Intake Packet To be completed by patient Minor Intake Packet To be completed by parent/guardian PATIENT IDENTIFICATION INFORMATION First Name Middle Home Phone Last Name Work Phone EXT DOB / / Age Cell Phone Address: Sex: F M (Circle one) EMERGENCY CONTACT INFORMATION Name Relationship Phone Rev Mar 2014 PLEASE COMPLETE ALL PAGES Page 1 of 7

2 GENERAL BACKGROUND Education (highest grade/degree completed): Occupation Employer Marital Status: Never Married Married With Partner Separated/Divorced Widowed (Circle one) If separated, divorced or widowed, year If currently married, Spouse s Name Age Year Married Spouse s Education Occupation Employer Children s Names and Ages Who lives in your home with you? How would you rate your support system (spouse/partner, extended family, friends, co-workers)? Excellent Good Fair Poor (Circle one) Are you having any problems with your job or school? Yes No (Circle one) If yes, please describe What do you do for fun? To what ethnic group do you belong? (Circle one) African-American Anglo Hispanic Native-American Other Where did you grow up? Who raised you? How many siblings do you have? What are the ages of your siblings? If anyone in your family of origin (mother, father, siblings, grandparents, uncles, aunts, 1 st cousins) had or has trouble with eating disorders, substance abuse, schizophrenia, bipolar disorder (i.e., manic-depression), depression, or other major emotional problems, please list them here. Rev Mar 2014 PLEASE COMPLETE ALL PAGES Page 2 of 7

3 PHYSICAL HEALTH Current Health Problems Allergies Past Major Health Problems Please list ALL medications (including homeopathic) you are taking. Please include dosages Medication Dosage Medication Dosage Primary Care Physician (family doctor) Telephone: Fax: List any other doctors you are seeing How much do you weigh? pounds How tall are you? feet inches FEMALES ONLY When was your last menstrual cycle? Month: Year: Are you on birth control/contraceptive medication? Yes No If yes, which one? How old were you when you had your first period? Years DAILY HABITS Do you currently use. (circle yes/no) If yes, on average, how many Tobacco No Yes Cigarettes per day? Caffeine No Yes Cups per day? Alcohol No Yes Drinks per day? Recreational drugs No Yes Daily usage? Rev Mar 2014 PLEASE COMPLETE ALL PAGES Page 3 of 7

4 How many meals do you eat on a typical weekday? How many meals do you eat on a typical weekend day? Do you participate in a regular exercise routine? Yes No (Circle one) If Yes, please describe your routine. What do you do to manage stress? EMOTIONAL HISTORY AND CURRENT PROBLEMS Briefly describe the problem or concern that brings you here today, and when it began List any significant changes or stressors in your life in the last year Place a check beside each diagnosis you have ever been given (whether or not you believe it to have been accurate). Anorexia Nervosa Anxiety or Panic Disorder Bipolar Disorder Binge Eating Disorder Other please list or describe: Bulimia Nervosa Depression Obsessive Compulsive Disorder Personality Disorder Post Traumatic Stress Disorder Schizophrenia Have you ever experienced any of the following as a child or adult? (Circle Yes or No for each item.) Sexual Abuse Yes No Physical Abuse Yes No Emotional Abuse Yes No Victim of Crime Yes No Suicidal Thoughts Yes No Suicide Attempt Yes No Other trauma Yes No Rev Mar 2014 PLEASE COMPLETE ALL PAGES Page 4 of 7

5 If you have been in therapy in the past, please indicate with whom and when (to the best of your recollection). Name of therapist When did you work with him/her? (month/year to month/year) Have you ever had problems with alcohol or drug abuse? Yes No (Circle one) Have you ever been in treatment for substance abuse? Yes No (Circle one) If you have been in treatment specifically for substance abuse, please indicate what program(s) and when? Program Name and Location Dates (month/year to month/year) IF YOU DO NOT HAVE AN EATING DISORDER, YOU ARE NOW DONE WITH THIS QUESTIONNAIRE. IF YOU DO HAVE AN EATING DISORDER, OR ARE UNSURE WHETHER YOU DO, PLEASE CONTINUE ONTO THE NEXT PAGE. Rev Mar 2014 PLEASE COMPLETE ALL PAGES Page 5 of 7

6 EATING DISORDER HISTORY How old were you when you first struggled with difficult feelings, thoughts, and/or behaviors about food or weight? Years Have you struggled with these feelings, thoughts, and/or behaviors continuously since they began? Yes No If you have had periods of no symptoms since the first onset of your ED, list the start & end dates of each period and what you think enabled you to give up the behaviors and what you think triggered your slip back to them. (If you are unsure of dates, estimate them.) Start & End Dates: Enabled stopping: Triggered relapse: Start & End Dates: Enabled stopping: Triggered relapse: Start & End Dates: Enabled stopping: Triggered relapse: What is the most and least you have weighed since age 13 and when was that? Lowest weight since age 13: Dates: Highest weight since age 13: Dates: If you have ever been hospitalized or participated in either a Partial Hospitalization or Intensive Outpatient Program for eating disorders, please list them here. (Add paper if necessary.) Program Name & Location (city/state) Dates you Participated Outcome what was helpful and what was not? Rev Mar 2014 PLEASE COMPLETE ALL PAGES Page 6 of 7

7 Check all the behaviors that best describe your CURRENT or MOST RECENT eating disorder symptoms. Restrict food intake Check body/appearance very often Binge eat Try to completely avoid certain foods Self-induce vomiting Eat in the middle of the night Feel compelled to exercise Chew and then spit out the food Abuse laxatives Abuse diuretics Please describe any other problems you have with food and/or weight. Have food/eating rituals Diet Use drugs/alcohol to control appetite Feeling fat Think about weight/food a lot Circle the number on the scale below to indicate how strongly you believe you need treatment for an Eating Disorder now Positive I do not need it sure I do not need it Not sure what I think right now sure I need it Positive I need it Circle the number on the scale below to indicate how you are for treatment right now Not at all Mostly not Neither nor un Totally Circle the number on the scale below to indicate how you are that you will benefit from treatment Not at all un Neither nor un Totally Rev Mar 2014 PLEASE COMPLETE ALL PAGES Page 7 of 7

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