Eating disorder assessment

Initial intake assessment

submit questions:

Why are you asking for help at this time?
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  What are you most struggling with?

Motivation and support:

How does your family see your chances of coming to our center?
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  Why do you need intensive help now, not 30 days ago or a month later?
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  If 100% means 100% commitment, how do you promise to give up eating disorders and recover? [Please give the answer as a percentage.]

Past treatment history:

Start with your first treatment and list the dates, facilities and professionals for your treatment. [inpatient/outpatient date; doctor/therapist name and phone number]
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  How do you feel about the treatment you are receiving?
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  Does it help you? If so, in what way?
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  If it didn't help in the past, why not?

Medication:

Non-psychiatric, general medicine you are currently taking:
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  History of psychiatric drugs from the beginning to the present:
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  Have you ever helped drugs in the past?
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  Are there immediate family members taking psychiatric drugs? Which family member and which drugs?
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  Is the medicine you are taking now helpful?
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  If you are not taking medication at the moment, would you consider taking psychiatric medication?

Family history:

[Answer the following questions about your family and extended family.]

Are you married, single or divorced?
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  How many children are there in your family?
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  What is the birth order of your home country?
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  How is your parents? marriage?
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  Any family history of emotional, physical or sexual abuse?
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  Any history of family crimes?
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  Any family history of bipolar or mental illness?
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  Any family history of an inpatient psychiatric hospital?
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  Is there a family history of alcohol or substance abuse?
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  Describe your relationship with your mother:
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  Describe your relationship with your father:
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  Describe your relationship with your spouse, if you are married:

Medical history:

Do you have any current medical problems or conditions?
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  Have you had any serious accidents? If yes, please explain.
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  Are you hospitalized for any reason? If yes, please explain.

Patient history and current status:

Have you had any serious losses in your life? What, who, when?
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  Have you experienced the tragic events in your life?
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  Are you under tremendous pressure now?
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  What is the current source of stress in your life?
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  Have you experienced any sexual, physical, emotional or abusive behavior recently or during your childhood? If yes, please specify:

Eating disorders history:

When did you first feel depressed?

Describe the history of your depression:

When did you start to suffer from eating disorders?
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  How did your eating disorder begin?
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  Tell me how your eating disorder develops:
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  What is your current height and weight?
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  What is the most important thing you have ever said?
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  Have you ever weighed anything and when?
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  Have you abused/used over-the-counter diet pills, street drugs, laxatives or diuretics? If so, when and what?
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  Are you carnival and cleaning? How much food and how many times?
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  What is your estimated daily calorie intake at this time?

Describe your exercise habits:

What do you think of your body?
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  What is the weight you have gained or reduced in the past 60 days?

Legal Issues:

Have you been arrested? If yes, please explain.
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  Have you ever been to the car? If yes, please explain.
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  Have you been arrested for drunk driving?
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  Have you ever abused anyone in any way?

Education background / attention:

Have you ever been diagnosed with mental retardation, learning disabilities or ADHD?
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  Have you ever been to a school resource or special education course?
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  How did you work with the class content, children and teachers at school?
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  Are there any areas of struggle or exceptional achievement in school?

Current educational pursuits / work records and current work:

What is your current GPA?
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  What is your high school GPA?
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  Special interest in school or profession:
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  Do you have a job now? If so, where do you work, what do you do?
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  What are your future education and volunteer goals?

Family involvement:

Do you live with your immediate family? [Yes or no]
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  How close are your closest relatives in geographical location?
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  Do you often visit your family by phone or in person?
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  What happened when you were with them?

Mental state:
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  Functional level:

Do you have a job?
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  Have you lost your job recently?
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  Can you play a role in your work?
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  Are you going to school now?
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  How are you in class?
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  Are you absent or have a decline in your studies? please explain:
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  Can you take care of yourself?
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  Can you take care of your children?
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  Are you social or isolated? Please describe:

Mental symptoms:

Potential suicide/self-harmlessness, mild, moderate, severe, current suicidal ideation, intention, past attempts: current suicide plan: self-harm/harmfulness - current, past [description]:
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  There is no violent potential, mild, moderate, serious, verbal aggressive, and physically aggressive. Please describe:
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  Bad Reality Test/Dissolution Event List Defects: Memory, Delusion, Judgment, Avoidance, Confusion, Suspicious, Auditory, Phantom, Perception
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  Emotional change/emotional inconsistency, tearful, inattention, worthless, desperate, guilty, unstable, angry, retreating, frustrated, euphoric, lack of interest, making decisions, lack of motivation, influence: other :
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  MOOD SWINGS Description:
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  DYSFUNCTIONAL SLEEPING PATTERNS No, early morning awakening, frequent awakening, excessive sleep, difficulty falling asleep, sleepless night
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  No function regression mode, bulimia [description], anorexia [description], appetite change, recent weight loss/increased, compulsive thinking or obsessive-compulsive pattern/ceremony [description]
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  No, moderate, severe, panic, symptom, fear or phobia
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  Substance abuse, alcohol [quantity, frequency, last drink], drugs [type and frequency], prescription/over-the-counter transactions:
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  The history of abuse is not, sex, body, emotion, description:

Diagnostic impression [preliminary]:
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  DSMIV, Axis I, II, III, IV, V, medical issues, current stressors, current GAF, highest GAF of the past year:

Treatment recommendations and needs:

Outpatient, inpatient, day plan
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  Nutrition clinic
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  Possible medication requirements:
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  Possible medical consultation needs:
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  Possible test/assessment requirements:

Additional comments or concerns:

Author: Michael E. Berrett, Ph.D.

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Orignal From: Eating disorder assessment