• 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___

     

     

    Double-click to edit this text...

  • Should be Empty: