Eating Disorders/Disordered Eating Addendum

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Name of Client (or Personal Representative)*
MM slash DD slash YYYY


*The frequency could be, on average, monthly, 2x month, weekly, daily, or multiple times per day
Restrictive Eating Past History
Self-induced Vomiting Past History
Binge Eating Past History
Laxative Abuse Past History
Diet Pills Past History
Compulsive Exercise Past History
Calorie Counting Past History
Body Checking Past History
Checking Weight Past History
Guilt After Eating Past History
Other Symptom Past History
Other Symptom Past History
*Please exclude pregnancy, if applicable, from this answer.
MM slash DD slash YYYY
MM slash DD slash YYYY
Physical Symptoms associated with Eating Disorder Onset
*If you are experiencing one or more of these symptoms, please contact your primary care physician for medical follow-up and/or go to the nearest emergency room.
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