Eating Disorder Questionnaire

Eating Disorder Questionnaire
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent’s Name If Under 18

First NameLast Name
Primary Care Provider*
How did you hear about our program?*
Do you regularly overeat or binge eat?*
Do you regularly engage in vomiting?*
Do you use laxatives on a regular basis?*
How many per day?
Do you limit your food or liquid intake?*
Do you have a preoccupation with food, weight, body image?*
Have you had a recent increase/decrease in your weight in the last year?*
How many pounds?

0-55-1010-2020-50Don’t know
Current Height*
Current Weight*
Date of Last Weight*

MonthDayYear
Date
Are you currently seeing a therapist for these difficulties or for other mental health concerns?*
It is our standard procedure that you complete a Release of Information for your current therapist if you are seeing one.
If yes, what is the provider’s name?
If yes, is the provider a psychiatrist?
Does the provider prescribe medication?
Have you sought assistance for these difficulties in the past?*
If yes, what is the provider’s name?
When did you seek assistance?
Are you currently in the hospital or have you been discharged in the last two weeks?*
Should be Empty: