Eating Disorder Assessment Intake Form

Personal Information

Name Date of Birth Gender Female Male Non-binary Other Prefer not to say Contact Number Email

Reason for Assessment

Please describe your concerns

Medical History

Have you been previously diagnosed with an eating disorder? Yes No If yes, please provide details Are you currently taking any medications? Do you have any significant medical conditions?

Eating Patterns

How many meals do you eat per day? Do you ever feel out of control while eating? Often Sometimes Rarely Never Do you engage in behaviors to prevent weight gain (e.g., vomiting, laxatives, over-exercising)? Yes No If yes, please specify behaviors and frequency

Body Image and Weight Concerns

How do you feel about your body and weight? Are you currently trying to change your weight or shape? Lose weight Gain weight Maintain weight Not sure

Additional Information

Do you have a support system? What do you hope to achieve from this assessment?