Eating Disorder Screening Intake

Full Name Date of Birth Gender Contact Information

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How did you hear about us?

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Please describe your current eating or body concerns Describe your eating patterns (meals, snacks, restrictions, etc.) Any episodes of binge eating? Any compensatory behaviors (vomiting, laxatives, excessive exercise)? Current Weight (if known) Current Height How do you feel about your body? Current or past mental health diagnoses or concerns Current or past physical health diagnoses Current medications Have you lost a significant amount of weight intentionally? Do you feel out of control while eating? Do you avoid certain foods or groups of foods? Do you feel distressed about your eating behaviors?