Eating Disorder Questionnaire

Eating Disorder Questionnaire
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent’s Name If Under 18

First Name Last 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?

0-5 5-10 10-20 20-50 Don’t know
Current Height *
Current Weight *
Date of Last Weight *

Month Day Year
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: