New Patient Intake Form
Behavioral Nutrition Assessment
Full Name
*
First Name
Last Name
DOB
-
Month
-
Day
Year
Date of birth
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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What Type of support are you looking for?
*
Anorexia Nervosa
Avoidant Restrictive Food Intake Disorder
Binge Eating Disorder
Bulimia Nervosa
Disordered Eating
Emotional Eating
Night Eating
Stress Eating
Medical Conditions (Diabetes, PCOS, Renal Disease, Liver Disease, Thyroid Issues, etc,...
IMPORTANT (Anorexia or Bulimia Nervosa)
We require all new patients have EKG clearance from a cardiologist/physician if you have not already had one recently.
PCP Name
PCP Phone
PCP Fax
You will need an EKG clearance from a cardiologist/physician.
If you have had an EKG in the past 30 days, please have your doctor's office fax the results to our office. 888-434-5097
You will need recent blood work to schedule your intial assessment.
If you have had recent labs in the past 30 days, please have your doctor's office fax the results to our office at 888-434-5097
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Have you been deliberately trying to limit the amount of food you eat to influence your weight or body shape?
Yes
No
Has thinking about food or eating made it very difficult to concentrate on things you are interested in?
Yes
No
Have you tried to control your weight or shape by making yourself sick (vomit) or taking laxatives?
Yes
No
Have you exercised in an excessive way as a means of controlling your weight?
Yes
No
Do you feel out of control when you eat?
Yes
No
Do you eat more rapidly than normal?
Yes
No
Do you eat until feeling uncomfortably full?
Yes
No
Do you eat large portions when not physically hungry?
Yes
No
Do you eat alone because of feeling embarrassed?
Yes
No
Do you find yourself having feelings of guilt or shame about your eating habits?
Yes
No
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Is this your first time seeking treatment?
Yes
No
Are you Diabectic?
Yes
No
Do you have any medical conditions we should be aware of, which are not eating disorder specific?
Health Insurance Policy Name
Please Select
Aetna
BCBS
BMC
Harvard Pilgrim
MA General Brigham
Tufts
United Health Care
Fallon
Tricare
Trustmark
National General
Humana
Other
Is Your Insurance HMO, PPO or MASS Health Insurance
please write HMO, PPO, MASS Health
Insurance ID
Submit
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