Eating Disorder Psychological Assessment Form
Personal Information
Full Name
Date of Birth
Age
Gender
Contact Information
Medical History
Physical Health/Medical Conditions
Past Psychiatric History
Current Medications
Eating Behaviour History
Onset of Eating Issues
Current Eating Patterns
Binge Episodes
Purging Behaviours (vomiting, laxative use, etc.)
Exercise Patterns
Body Image & Cognition
Body Image Concerns
Preoccupation with Weight/Shape
Psychosocial Factors
Family History (Eating Disorders, Mental Health)
Social Support Network
Current Life Stressors
Additional Notes
Other Relevant Information