September 13, 2022by Lee Germeroth Eating Disorders/Disordered Eating Addendum "*" indicates required fields Who is your provider?*Elian M. Beattie, M.S., LMHCCecelia Tarr, M.S.W.Name of Client (or Personal Representative)* First Last Email* Relationship to Client Date* MM slash DD slash YYYY Symptoms*The frequency could be, on average, monthly, 2x month, weekly, daily, or multiple times per dayRestrictive Eating Frequency Restrictive Eating Past History Yes No Self-induced Vomiting Frequency Self-induced Vomiting Past History Yes No Binge Eating Frequency Binge Eating Past History Yes No Laxative Abuse Frequency Laxative Abuse Past History Yes No Diet Pills Frequency Diet Pills Past History Yes No Compulsive Exercise Frequency Compulsive Exercise Past History Yes No Calorie Counting Frequency Calorie Counting Past History Yes No Body Checking Frequency Body Checking Past History Yes No Checking Weight Frequency Checking Weight Past History Yes No Guilt After Eating Frequency Guilt After Eating Past History Yes No Other Symptom Frequency Other Symptom Past History Yes No Other Symptom Frequency Other Symptom Past History Yes No Please describe a typical day of your eating patterns:Height: Current Weight: Highest Weight: *Please exclude pregnancy, if applicable, from this answer.Date MM slash DD slash YYYY Lowest Weight: Date MM slash DD slash YYYY Any significant fluctuations in weight over the past six months- year? Physical Symptoms associated with Eating Disorder Onset Amenorrhea (lack of menses) Irregular Menses Hair Loss Dental Issues Fainting Chest Pain Muscle Cramping Low Heart Rate Heart Palpitations Constipation Blood in stool or vomit Numbness/ Tingling in Extremities Edema *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.Have you ever received eating disorder specific care? If so, when and where?Do you have any goals related to your eating disorder recovery?EmailThis field is for validation purposes and should be left unchanged. Please wait for the confirmation before closing out of the form.