Amber Monroe, MFT 49337
Licensed Marriage and Family Therapist
8355 La Mesa Blvd.
La Mesa CA, 91942
619-382-5154
Eating Disorder Assessment
My thoughts about food
Food controls my life? Yes__ No__ Sometimes___
Preoccupied with food? Yes__ No__ Sometimes___
Feel guilt after eating? Yes__ No__ Sometimes___
Like stomach to be empty? Yes__ No__ Sometimes___
Hate feeling full? Yes__ No__ Sometimes___
I feel disgusting after I eat? Yes__ No__ Sometimes___
I want to eat all the time? Yes__ No__ Sometimes___
Feel powerful when I don't eat? Yes__ No__ Sometimes___
I have always been a picky eater? Yes__ No__ Sometimes___
Read diet books/research the web? Yes__ No__ Sometimes___
How long have you been having these types of thoughts? _____________
Body Image
Fearful of being overweight? Yes__ No__ Sometimes___
Preoccupied with being thinner? Yes__ No__ Sometimes___
Look in the mirror frequently? Yes__ No__ Sometimes___
Avoid mirrors frequently? Yes__ No__ Sometimes___
Body check myself? Yes__ No__ Sometimes___
Compare myself to other? Yes__ No__ Sometimes___
Desires to be at a goal weight? Yes__ No__ Sometimes___
What is your goal weight? _______ n/a____
How many times per week are you weighing yourself? ________N/A _____
Do you have a weighing ritual? Yes__ No__ Sometimes___
Measure myself with tape measure or clothes Yes__ No__ Sometimes___
How do you feel about your body? ______________________________
How often are you ruminating about your body? ____________________
How long have you felt this way? ________________________________
Exercising
Do you exercise? Yes__ No__ Sometimes___
I think about burning up calories when you exercise? Yes__ No__ Sometimes___
How many times per week do you exercise? ______________N/A__
How long do you exercise? __________N/A__
What kind of exercise do you do? _____________________________N/A__
Where do you exercise? ____________________________________N/A__
Intensity of exercise on a 1-10 scale? _____________N/A__
Do you hide your exercising? Yes__ No__ Sometimes ___N/A__
Restricting
Avoid foods high in carbs or sugar? Yes__ No__ Sometimes___
Are you Vegetarian? Yes__ No__ Sometimes___ For how long? _____
Are you Vegan? Yes__ No__ Sometimes___ For how long? _____
Gluten Free? Yes__ No__ Sometimes___ For how long? _____
Cutting out certain food groups? Yes__ No__ Sometimes___
Do you have any forbidden/Bad foods? Yes__ No__ Sometimes___
Eat only “diet” foods? Yes__ No__ Sometimes___
Fixates on the quality of food? Yes__ No__ Sometimes___
Eat only healthy foods? Yes__ No__ Sometimes___
Refuse foods of certain textures? Yes__ No__ Sometimes___
Do you ever fast? Yes__ No__ Sometimes___ How often? ____ How Long? ____
Avoid eating when hungry? Yes__ No__ Sometimes
Avoids social events with food? Yes__ No__ Sometimes___
Do you skip meals? Yes__ No__ Sometimes___ Which meals primarily? __________
Do you have hunger cues? Yes__ No__ Sometimes___
Are you dishonest with how much you eat? Yes__ No__ Sometimes___
Chew & spit out your food? Yes__ No__ Sometimes___
Feels nauseous when eating or afterwards? Yes__ No__ Sometimes___
Fear of choking or vomiting when eating? Yes__ No__ Sometimes___
Increase fluid consumption? Yes__ No__ Sometimes___ How much daily? ______
Decrease fluid consumption? Yes__ No__ Sometimes___
Others pressure me to eat? Yes__ No__ Sometimes___
Counting Calories? Yes__ No__ How many calories per day are you trying to stay under? ________
How long have you been restricting your food? ___________
Binging
Feel like you can’t stop eating? Yes__ No__ Sometimes___
Eat for more than 1hr at a time? Yes__ No__ Sometimes___
Eat large portions of food? Yes__ No__ Sometimes___
Eat until you feel sick? Yes__ No__ Sometimes___
Often get several helpings? Yes__ No__ Sometimes___
Purchase food several times per day? Yes__ No__ Sometimes___
Snacks all day long? Yes__ No__ Sometimes___
Hides food/wrappers? Yes__ No__ Sometimes___
Friends/Family notice food missing? Yes__ No__ Sometimes___
Eats in secret? Yes__ No__ Sometimes___
Exercises or Fast before a binge? Yes__ No__ Sometimes___
What types of foods do you typically binge on? ___________________
How many times per week are you binging? ___________________N/A___
How long have you been binging for? _____________________
When was your last binge? _____________________________
Please give an example of your last binge? ___________________________________________________
Purging
Have the impulse to purge after meals? Yes__ No__ Sometimes___
Purge after I eat? Yes__ No___ How many times per week OR month? ____________
When was the last time you purged? ___________
Hides the purging behavior? Yes__ No__ Sometimes___
Purges in other areas beside the toilet? Yes__ No__ Sometimes___
Uses an object to help purge to purge? Yes__ No___
How long have you been purging for? ______________________N/A___
Do you use diet pills? Yes__ Last Use _____No__ How many times per day/week/month? ____________
Do you use diuretics? Yes__ Last Use _____No__ How many times per day/week/month? ____________
Use laxatives? Yes__ Last Use _____No__ How many times per day/week/month? ____________
Use enemas? Yes__ Last Use _____No__ How many times per day/week/month? ____________
Use of diet pills/diuretics/laxatives or enemas was: ________________________________________
Food Rituals
Long history of yo-yo dieting? Yes__ No__ Sometimes___
Participated in a liquid fasting program? Yes__ No__ Sometimes___
Measures or weighs your food? Yes__ No__ Sometimes___
Refuse to let others plate or prepare your food? Yes__ No__ Sometimes___
Compares food to what others are eating? Yes__ No__ Sometimes___
Desire to eat from particular bowls/plates? Yes__ No__ Sometimes___
Avoids meal times/situations with food? Yes__ No__ Sometimes___
Loves to cook/bake but not eat? Yes__ No__ Sometimes___
Over use of condiments? Yes__ No__ Sometimes___
Collects/Hoards food recipes? Yes__ No__ Sometimes___
Reads food labels? Yes__ No__ Sometimes___
Eats food rapidly? Yes__ No__ Sometimes___
Eats food very slowly? Yes__ No__ Sometimes___
Separates foods into categories? Yes__ No__ Sometimes___
Eats food groups in a particular order? Yes__ No__ Sometimes___
Cut food into small pieces? Yes__ No__ Sometimes___
Excessively chews foods? Yes__ No__ Sometimes___
Move food around on your plate? Yes__ No__ Sometimes___
Have to bite your food in particular ways? Yes__ No__ Sometimes___
Foods on your plate can’t touch? Yes__ No__ Sometimes___
Medical Concerns
Are you diabetic? Yes__ No__
How many hours do you sleep a night on average? __________
Are you fatigued often? Yes__ No__ Sometimes___
Frequently feel cold? Yes__ No__ Sometimes___
Frequently feel hot? Yes__ No__ Sometimes___
Chest Pain? Yes__ No__ Sometimes___
Dizzy? Yes__ No__ Sometimes___
Headaches? Yes__ No__ Sometimes___
Weakness? Yes__ No__ Sometimes___
Fainting Spells? Yes__ No__ Sometimes___
Poor Concentration? Yes__ No__ Sometimes___
Edema (Swelling)? Yes__ No__ Sometimes___
Acid Reflux? Yes__ No__ Sometimes___
Stomach Pain? Yes__ No__ Sometimes___
Throat Pain? Yes__ No__ Sometimes___
Involuntary regurgitation? Yes__ No__ Sometimes___
Broken Blood vessels in eyes? Yes__ No__ Sometimes___
Swollen neck glands? Yes__ No__ Sometimes___
Lanugo Hair? Yes__ No__ Sometimes___
Bruises easily? Yes__ No__ Sometimes___
Constipation? Yes__ No__ Sometimes___
Problems w/ Nails/Hair/Teeth? Yes__ No__ Sometimes___ Please Explain: _______________
How often do you menstruate? ________Last Cycle_________ N/A____
Additional Medical Concerns? ____________________________
Does your primary care provider aware of your ED symptoms? Yes__ No___ Somewhat_______
When was your last doctor’s appointment? __________________
When were your last labs drawn? _________________________
Weight History
Height: __________
Current weight: __________
Weight loss/gain over the last 3 months? __________N/A__
Highest weight: __________When? _______
Lowest weight: __________ When? _______
I believe I have an Eating Disorder: Yes__ No__ Sometimes___
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