I N T A K E Q U E S T I O N N A I R E

Transcription

1 I N T A K E Q U E S T I O N N A I R E NAM E AG E REFERENT W H Y T R E A T M E N T N O W? I M P A C T O F P R I O R T R E A T M E N T E X P E R I E N C E S TELL US WHY YOU ARE PURSU ING TR E ATMENT AT THIS TIME : WHAT ASPEC TS OF B EING IN TR E ATMENT CONCER N YOU? IF YOU HAVE B EEN IN TR E ATMENT PR E VIOUSLY, WHAT AR E SOME OF THE POSITIVE OR NEGATIVE E XPER IENCES THAT MAY IMPAC T YOUR E XPER IENCE AT OLIVER - PYAT T CENTER S? L I F E S I T U A T I O N CU R R ENT LIVING AND SOCIAL ENVIRONMENT ( WHO YOU L IVE WITH / SET TING YOU L IVE IN ) : HOW DO YOU FEEL YOUR CU R R ENT LIVING ENVIRONMENT I M PAC TS YOU? WHO IS I N YOUR SU PPORT SYSTEM ( E.G., FA MILY, FR IENDS, THER APIST )? C AN YOU DESCR IBE A TYPIC AL OR R ECENT DAY IN YOUR LIFE THAT WOULD HELP US UNDER STAND YOU? 6150 SW 76th Street South Miami, FL HEAL (4325)

2 A D D I T I O N A L B A C K G R O U N D I N F O R M A T I O N AR E YOU INVOLVED IN ANY SPORTS OR E XERCISE? WHAT MOTIVATES / MOTIVATED YOU TO PARTICIPATE IN SPORTS OR E XERCISE? DO YOU HAVE ANY PARTICUL AR INTER ESTS, PASSIONS, OR HOB B IES THAT YOU C AN TELL US ABOUT? DO YOU HAVE ANY DIE TARY REQUIREMENTS DUE TO RELIGION ( E.G., KOSHER ) OR MEDIC AL CONDITION YOU HAVE DOCUMENTATION FOR ( E.G., DIABETES, FOOD ALLERGIES)? HAVE YOU BEEN FED BY NON - OR AL ROUTES AND / OR RECEIVED SUPPLEMENTS AS YOUR PRIMARY SOURCE OF NUTR ITION? IF SO, PLE ASE PROVIDE DE TAILS : HAVE YOU HAD ANY T YPE OF GI SURGERY ( E.G., GASTR IC BYPASS, RESEC TIONING )? IF SO, PLE ASE PROVIDE DATE (S) AND OUTCOME : DID YOU E XPER IENCE AN OUTCOME THAT YOU FELT WAS POSITIVE OR NEGATIVE WITH R EGAR D TO YOUR PHYSIC AL AND / OR EMOTIONAL HE ALTH? IF SO, PLE ASE DESCR IBE : E A T I N G D I S O R D E R S Y M P T O M S H EIGHT USUAL WEIGHT H IGHEST WEIGHT / AG E CU R R ENT WEIGHT DESIRED WEIGHT LOWEST WEIGHT / AG E WEIGHT B EFOR E ONSE T OF E ATING DISOR DER / AG E R ECENT WEIGHT CHANGES ( DE SCR IBE WEIGHT LOSS OR G AIN PAT TERNS OVER THE PAST 12 MONTHS ) CU R R ENT C ALOR IC INTAKE ( INCLUDING SUPPLE MENTS) DO YOU R ESTRIC T YOUR FOOD INTAKE? NO YES, B U T ONLY IN THE PAST ( WHEN DID YOU STOP? ) YES, I CU R R ENTLY R ESTR IC T IF YES, HOW DO YOU / DID YOU R ESTR IC T ( E.G., C ALOR IES, FASTING, SPECIFIC FOOD AVOIDANCE)? 2

3 DO YOU BINGE EAT? ( BINGE EATING IS DEFINED AS EATING AN AMOUNT OF FOOD THAT IS LARGER THAN THE AVERAGE PERSON WOULD CONSUME, ACCOMPANIED BY A SENSE OF BEING OUT OF CONTROL.) NO YES, BUT ONLY IN THE PAST ( WHEN DID YOU STOP?) YES, I CURRENTLY BINGE IF YES, HOW OFTEN DO YOU / DID YOU BINGE PER DAY / WEEK ON AVERAGE? DO YOU HAVE OTHER OVER- EATING PATTERNS SUCH AS GRAZING ON FOOD ALL DAY? WHAT ARE YOUR PREFERRED BINGEING AND / OR GRAZING FOODS? DO YOU PURGE? NO YES, BUT ONLY IN THE PAST ( WHEN DID YOU STOP?) YES, I CURRENTLY PURGE IF YES, HOW OFTEN DO YOU / DID YOU PURGE PER DAY / WEEK ON AVERAGE? DO YOU ABUSE LAXATIVES? NO YES, BUT ONLY IN THE PAST ( WHEN DID YOU STOP?) YES, I CURRENTLY ABUSE IF YES, WHAT KIND OF LAXATIVES DO YOU / DID YOU USE, AND WHAT AMOUNT PER DAY / WEEK ON AVERAGE? DO YOU CURRENTLY USE WEIGHT- LOSS PILLS? NO YES IF YE S, LIST TYPE, QUANTITY, AND FREQUENCY DO YOU DRINK AN EXCESSIVE AMOUNT OF WATER? NO YES DO YOU HAVE ANY FOOD RITUALS THAT CONCERN YOU? NO YES IF YES, PLEASE EXPLAIN: DO YOU HAVE AN UN HEALTHY RELATIONSHIP WITH EXERCISE? NO YES, I GET ANXIOUS OR IRRITABLE IF I CAN T ENGAGE IN MY EXERCISE ROUTINE YES, I OVER- EXERCISE ( HOW MANY HOURS PER DAY / WEEK?) YES, I EXERCISE AGAINST THE ADVICE OF A HEALTH CARE PROVIDER AND / OR DESPITE PAIN YES, I UNDER- EXERCISE EXPOSURE TO TRAUMA HAVE YOU BEEN PHYSICALLY ABUSED? NO YES HAVE YOU BEEN SEXUALLY ABUSED? NO YES DOES ANYONE IN YOUR FAMILY STRUGGLE WITH SUBSTANCE ABUSE, A MENTAL HEALTH ISSUE, OR AN EATING DISORDER? NO YES HAVE YOU LOST A CLOSE FAMILY MEMBER? NO YES OTHER: 3

4 PRIOR TREATMENT EXPERIENCES ( LIST PLACES, DATES, A ND HOW THEY IMPACTED YOU) INDIVIDUAL THERAPY INTENSIVE OUTPATIENT DAY TREATMENT / PARTIAL HOSPITALIZATION RESIDENTIAL INPATIENT PSYCHIATRIC INPATIENT MEDICAL CO- OCCURRING CONDITIONS LET US KNOW IF YOU HAVE EVER BEEN DIAGNOSED WITH AND / OR HAVE EXPERIENCED ANY OF THE FOLLOWING CONDITIONS THAT SOMETIMES ACCOMPANY EATING DISORDERS: DEPRESSION NO YES BIPOLAR DISORDER / MANIA / HYPOMANIA / EXTREME MOOD FLUCTUATION NO YES PREMENSTRUAL SYMPTOMS NO YES POSTMENOPAUSAL SYMPTOMS NO YES ATTENTION DEFICIT DISORDER NO YES PANIC DISORDER NO YES SOCIAL PHOBIA NO YES ANXIETY DISORDER NO YES OBSESSIVE COMPULSIVE DISORDER NO YES OTHER IMPULSIVE DISORDER ( E.G., SHOPPING, SEXUAL IMPULSIVITY, GAMBLING) NO YES EXCESSIVE/DISRUPTIVE USE OF INTERNET OR COMPUTER GAMES NO YES SUBSTANCE ABUSE NO YES ALCOHOL ABUSE NO YES HOARDING (OF FOOD OR POSSESSIONS ) NO YES SHOPLIFTING OR STEALING NO YES ANXIETY OR INABILITY TO SHOP FOR FOOD AND / OR CLOTHING NO YES ANXIETY OR INABILITY TO EAT IN RESTAURANTS OR TAKE- OUT FOODS NO YES OTHER: 4

5 S ELF- HARM DO YOU HAVE SUICIDAL THOUGHTS? NO YES HAVE YOU EVER TRIED TO COMM IT SUICIDE? NO YES IF YES, HOW AND WHEN? DO YOU DO OTHER SELF- HARMING BEHAVIORS ( E.G., CUTTING, BURNING, PICKING)? NO YES IF YES, WHERE ON YOUR BODY? CAN YOU COMMIT TO SAFETY WHILE UNDER THE CARE OF OLIVER- PYATT CENTERS? NO YES PSYCHIATRIC MEDICATION HISTORY WHAT MEDICATIONS ARE YOU CURRENTLY TAKING? WHAT MEDICATIONS HAVE YOU TAKEN IN THE PAST? ( PROVIDE WHATEVER INFORMATION YOU REMEMBER) MEDICAL HISTORY DATE OF LAST PHYSIC AL EXAM CURRENT MEDICAL CONDITIONS CURRENT MEDIC ATIONS FOR ANY MEDIC AL CONDITIONS AGE OF ONSET OF MENSES / LAST MENSTRUAL PERIOD PAST AND / OR RESOLVED MEDICAL CONDITIONS PAST MEDIC AL HOSPITALIZATIONS SERIOUS INJURIES TO THE SPINE OR HEAD 5

6 A D D I T I O N A L I N F O R M A T I O N YOU MAY E XPER IENCE PER SONAL STRUGGLES DURING YOUR TR E ATMENT. DO YOU FEEL IT WILL B E DIFFICULT TO SHAR E THOSE STRUGGLES WITH US? IF SO, PLE ASE E XPL AIN : PLE ASE LIST THREE PROMINENT STR ESSOR S YOU HAVE AT THIS TIME : WHAT AR E SOME STR ENGTHS AND WE AKNESSES YOU HAVE THAT MAY INFLUENCE THE COURSE OF YOUR TR E ATMENT? STRENG THS : AR E AS OF STRUGGLE : WHAT AR E SOME GOAL S YOU HAVE AT THIS TIME? SHORT-TER M : LONG -TER M : P R O S P E C T I V E C L I E N T SIGNATURE DATE PHONE O L I V E R - P Y A T T C E N T E R S S T A F F NAME SIGNATURE DATE 2O13 Oliver-Pyatt Centers. All rights reserved. 6