FAMILY WEIGHT HISTORY:
Is your mother currently living (Y/N)? ________ Mother’s age: _________
Describe Mother’s weight (check one):
- ________
severely underweight
- ________ underweight
- ________ average weight
- ________
slightly overweight
- ________ overweight
- ________ severely overweight
Is your father currently living (Y/N)? ________ Father’s age: __________
Describe Father’s weight (check one):
- ________ severely underweight
- ________ underweight
- ________ average weight
- ________ slightly overweight
- ________ overweight
- ________ severely overweight
Number of Siblings and names:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How many siblings are overweight? ________ underweight? ________
Does anyone in your family have a history of dieting and/or pre-occupation with food/weight?
(Y/N)? ________ Please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
BODY IMAGE HISTORY:
Please indicate how satisfied you feel with the way your body is proportioned:
- ________
very dissatisfied
- ________ dissatisfied
- ________ slightly satisfied
- ________ satisfied
- ________ very satisfied
Please indicate how you feel about the different areas of your body:
VD= very dissatisfied D= dissatisfied SS= slightly satisfied S= satisfied VS= very satisfied
- ________ face
- ________ arms
- ________ shoulders
- ________ breasts
- ________
stomach
- ________ buttocks
- ________ thighs
- ________ legs
- ________
nose
- ________ eyes
- ________ ears
- ________ hair
Please indicate how you see yourself when you look in the mirror?
- ________ emancipated
- ________ thin
- ________ average
- ________ slightly overweight
- ________ overweight
- ________ extremely overweight
FOOD HISTORY:
Please record a sample of your daily intake (food and liquid). Please indicate a “P” the times in which food/liquid
was purged.
Breakfast: _________________________________________________________________________________
Snack:
____________________________________________________________________________________
Lunch:
____________________________________________________________________________________
Dinner:
____________________________________________________________________________________
Snack:
____________________________________________________________________________________
How comfortable are you with your current food behaviors?
- ________ not at all uncomfortable
- ________ slightly uncomfortable
- ________ uncomfortable
- ________ very uncomfortable
- ________ extremely uncomfortable
How ready do you feel to let go of the thoughts/behaviors associated with the eating disorder?
- ________ not at all ready
- ________ somewhat ready
- ________ ready
- ________ very ready
Please elaborate on reasons why you checked the above box:
__________________________________________________________________________________________
__________________________________________________________________________________________
How willing would you be to gain 5-10 pounds if you knew the behaviors/thoughts would diminish?
- ________ not at all willing
- ________ somewhat willing
- ________ willing
- ________ very willing
Please list the behaviors/thoughts that you would want to change:
__________________________________________________________________________________________
__________________________________________________________________________________________
At what age did you first become concerned with your weight? ________________________________________
At what age did you begin restricting your intake? __________________________________________________
At what age did you begin purging? _____________________________________________________________
At what age did you begin bingeing? ____________________________________________________________
Please check all symptoms you have felt since the development of your eating problems:
- ________ sore throat
- ________ feeling tired/weak
- ________ feeling bloated
- ________ constipation
- ________
stomach Pains
- ________ feeling cold
- ________ dizziness
- ________ swollen glands
- ________ sore joints
- ________
water retention
- ________ hair loss
- ________ muscle spasms/cramps
- ________ depression/irritability
- ________
over sensitivity to noise/touch/light
- ________ other (explain):
_____________________________________________________________________________________
_____________________________________________________________________________________
If you have a history of bingeing, please answer the following:
Please check the times you are most likely to binge:
- ________
8 -12 a.m.
- ________ 12 - 6 p.m.
- ________ 6 p.m. - midnight
- ________ midnight - 8 a.m.
Please check the places you are most apt to binge:
- ________
car
- ________ home
- ________ work/school
- ________ restaurant
- ________ other (explain):
_____________________________________________________________________________________
_____________________________________________________________________________________
FEELINGS HISTORY:
Please place a check next to the feelings that you have difficulty sitting with and/or expressing
(that may then
get expressed/released through your eating disorder):
- ________ anxiety
- ________ boredom
- ________ disappointment
- ________ confusion
- ________ anger
- ________ frustration
- ________
sadness
- ________ fear
- ________ guilt
- ________ hurt
- ________ jealousy
- ________ self-loathing
EXERCISE HISTORY:
How many minutes per day do you currently exercise? _______________________________________________
How many days per week do you currently exercise? ________________________________________________
Are you, or have you ever, been involved in serious training for any sport (Y/N)? __________________________
If Yes, please list those sports:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Sexual History: Have you ever engaged in sexual intercourse (Y/N)?____________________________________
Has anyone ever touched you in a way that felt uncomfortable, or forced you to participate in a sexual act
against
your will (Y/N)? _______________________________________________________________________
QUESTIONS:
What are some questions you would like to have addressed in your next therapy session:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What are some questions that you would like to have addressed in the course of your history?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
|
