Eating Disorder Nutrition Assessment Form
Personal Information
Full Name
Date of Birth
Age
Gender
Female
Male
Other
Prefer not to say
Contact Information
Medical History
Diagnosis (if known)
Duration of Eating Concerns
Other Relevant Medical Conditions
Medications & Supplements
Anthropometrics
Current Height (cm)
Current Weight (kg)
Highest Adult Weight (kg)
Lowest Adult Weight (kg)
Recent Weight Changes
Eating Patterns
Describe Typical Meal Pattern
Foods or Food Groups Avoided
Binge Episodes (Frequency/Triggers)
Compensatory Behaviors (e.g. vomiting, laxatives, overexercise)
Other Relevant Information
Body Image Concerns
Nutrition-Related Goals or Questions
Additional Notes