Lindnercenterofhope.org



Adult LCOH ED Program Intake FormDate:_____/_____/2010DOB: _____/_____/19____Name: ______________________________Nickname:______________________Name of person completing this section (if different than patient):________________________________Relationship to Patient: FORMCHECKBOX (1)Family Member FORMCHECKBOX (2)Physician FORMCHECKBOX (3)Other, please specify:_____________________Please answer the following questions to the best of your abilityWhat problems are you having which prompted you to come to the Lindner Center of HOPE? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What are your goals/expectations for treatment? ___________________________________________ ____________________________________________________________________________________________________________________________________________________________________ Eating Disorder HistoryThese questions are designed to help you obtain the best possible treatment specific to your needs. Please answer each question completely. Use the back of the page to complete your responses if needed.Food Intake:Do you have any “rules” or food patterns which limit your food intake? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf yes, please explain: _________________________________________________________________________________________________________________________________________________What is your estimated number of calories eaten daily?______________________________________Is there significant variability in the number of calories you eat daily? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf yes, please explain: _______________________________________________________________Describe a typical day of eating (if you do not have a typical day, please list what you ate yesterday):Describe what you would eat for a typical breakfast: _______________________________________What time do you typically eat breakfast? ____:____ am/pmDescribe what you would eat for a typical morning snack: ___________________________________Around what time do you typically eat that? ____:____ am/pmDescribe what you would eat for a typical lunch: __________________________________________Around what time do you typically eat that? ____:____ am/pmDescribe what you would eat for a typical afternoon snack: __________________________________Around what time do you typically eat that? ____:____ am/pmDescribe what you would eat for a typical dinner: _________________________________________Around what time do you typically eat that? ____:____ am/pmDescribe what you would eat for a typical evening snack(s): _________________________________Around what time do you typically eat that? ____:____ am/pmDo you restrict fluids? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf yes, please explain: _______________________________________________________________Do you eat food in a way that feels out of control and/or associated with a feeling of disconnected to physical hunger? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf yes, please explain: _______________________________________________________________Binge Eating (refers to a pattern of eating large amounts of food rapidly in a brief time period)Describe what happens during a typical binge (where are you, who are you with, what are you feeling, and what do you eat during a typical binge): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________Number of days you binged in the past month: _______________Average number of times per day you binged in the past month: ____________________Approximate age when you first binged: ____________________Compulsive Eating (refers to eating large amounts of food over an extended period (i.e. throughout the day) instead of all at once)Number of days you ate compulsively in the past month: _______________Approximate age when you first ate compulsively: ____________________What do you eat during a typical episode in which you eat compulsively? _______________________________________________________________________________________________________Purging BehaviorsDo you compensate for eating by using any of the following: Laxatives: FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf yes, quantity:_____ and frequency of use:_____day/wkDiuretics: FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf yes, quantity:_____ and frequency of use:_____day/wkFat absorbers: FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes If yes, quantity:_____ and frequency of use:_____day/wkDo you compensate for eating by vomiting? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, how many times each day is this occurring: ________________________________________Do you utilize diet pills or other medications (prescribed or over the counter) in an effort to suppress your appetite? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, which one(s) and how often: _____________________________________________________Approximate age when you began purging behaviors: ____________________Please provide any additional information you believe is important: _______________________________________________________________________________________________________________________________________________________________________________________________ExerciseAre you involved in any sports or exercise? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesWhat motivates you to participate in sports or exercise? ______________________________________________________________________________________________________________________How many hours per day have you exercised over the past month? ____________________________Approximately how many days have you exercised over the past month? _______________________Do you become irritable and/or anxious if you are not able to engage in your exercise routine? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesWas there a time when you exercised more or less? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, how much did you exercise: _____________________________________________________Do you exercise against the advice of a health care provider, or despite illness or pain? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesWeight HistoryDo you weigh yourself routinely? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, describe frequency: ____________________________________________________________Age:_______ and weight:__________ at the onset of eating disorder symptoms.Highest lifetime weight:__________Date:_______________EDO Staff OnlyCurrent Height:____________Current Weight:____________BMI:_______ [Calculate]Sitting BP:________ Pulse:______Standing BP:________ Pulse:______Lab work/ECG FORMCHECKBOX (0)Yes FORMCHECKBOX (1)NoLowest weight at current height:__________Date:______________Describe any weight fluctuations over the course of your life: __________________________________________________________________________________________________________________General ED InformationWhen did your eating disorder behavior first start? ________________________________________What behavior? ____________________________________________________________________List any health problems you have that may have been caused by your eating disorder: ____________________________________________________________________________________________________________________________________________________________________For women:Age of onset of first period: ____________________When was your last period? ____________________Are your periods irregular? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, describe: _____________________________________________________________________In the past two years, have you missed three or more periods? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesHave you ever been pregnant? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, what was the outcome?_________________________________________________________Past psychiatric treatment:Prior treatment experiences (list providers, places, dates and how it impacted you):Outpatient psychotherapy: FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes____________________________________________________________________________________________________________________________________________________________________Outpatient psychiatry/medication management: FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes____________________________________________________________________________________________________________________________________________________________________Intensive outpatient treatment: FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes____________________________________________________________________________________________________________________________________________________________________Day treatment/partial hospitalization: FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes____________________________________________________________________________________________________________________________________________________________________Residential treatment: FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes____________________________________________________________________________________________________________________________________________________________________Inpatient psychiatric hospitalization: FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes____________________________________________________________________________________________________________________________________________________________________Inpatient medical hospitalization: FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes____________________________________________________________________________________________________________________________________________________________________Have you ever been diagnosed with and/or have experienced any of the following conditions that sometimes accompany eating disorders: FORMCHECKBOX Depression FORMCHECKBOX Suicide attempt FORMCHECKBOX Bipolar disorder/mania/hypomania/extreme mood fluctuation FORMCHECKBOX Other impulsivity concerns (e.g., shopping, sexual inmpulsivity) FORMCHECKBOX Premenstrual symptoms FORMCHECKBOX Self-harming behavior FORMCHECKBOX Postmenopausal symptoms FORMCHECKBOX Substance abuse FORMCHECKBOX Attention deficit disorder FORMCHECKBOX Alcohol abuse FORMCHECKBOX Panic disorder FORMCHECKBOX Hoarding of food FORMCHECKBOX Social phobia FORMCHECKBOX Shoplifting or stealing FORMCHECKBOX Anxiety disorders FORMCHECKBOX Anxiety or inability to shop for food and/or clothing FORMCHECKBOX Obsessive compulsive FORMCHECKBOX Anxiety or inability to eat in restaurants or take out foodsWhich psychiatric medications have you taken in the past and what were the benefits and/or side effects you had from them? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you taking any psychiatric medications now? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf yes, please check all the current medications: FORMCHECKBOX Depakote FORMCHECKBOX Ambien FORMCHECKBOX Lamictal FORMCHECKBOX Lunesta FORMCHECKBOX Lithium FORMCHECKBOX Rozeram FORMCHECKBOX Neurontin FORMCHECKBOX Sonata FORMCHECKBOX Trileptal FORMCHECKBOX Somnote (chloral hydrate) FORMCHECKBOX Topamax FORMCHECKBOX Trazodone FORMCHECKBOX Tegretol FORMCHECKBOX Abilify FORMCHECKBOX Ativan FORMCHECKBOX Geodon FORMCHECKBOX Klonopin FORMCHECKBOX Risperdal FORMCHECKBOX Xanax FORMCHECKBOX Seroquel FORMCHECKBOX Valium FORMCHECKBOX Zyprexa FORMCHECKBOX Zyprexa Zydis FORMCHECKBOX Campral FORMCHECKBOX Antabuse FORMCHECKBOX Celexa FORMCHECKBOX Adderall FORMCHECKBOX Effexor FORMCHECKBOX Adderall XR FORMCHECKBOX Lexapro FORMCHECKBOX Concerta FORMCHECKBOX Paxil FORMCHECKBOX Focalin FORMCHECKBOX Prozac FORMCHECKBOX Focalin XR FORMCHECKBOX Wellbutrin XL FORMCHECKBOX Metadate FORMCHECKBOX Zoloft FORMCHECKBOX Metadate CD FORMCHECKBOX Cymbalta FORMCHECKBOX Ritalin FORMCHECKBOX Remeron FORMCHECKBOX Strattera FORMCHECKBOX Luvox FORMCHECKBOX Provigil FORMCHECKBOX DexedrineOther:Prescribing Physician:Please review the following and check any current symptoms that pertain to you: FORMCHECKBOX Depressed Mood FORMCHECKBOX Inflated self-esteem FORMCHECKBOX Stopped enjoying usual activities FORMCHECKBOX Don’t seem to need sleep FORMCHECKBOX Lost or Gained weight without meaning to FORMCHECKBOX Excessive talking FORMCHECKBOX Sleep too much or not enough FORMCHECKBOX Racing thoughts FORMCHECKBOX Agitated or sluggish FORMCHECKBOX Highly distractible FORMCHECKBOX No energy/always tired FORMCHECKBOX Try to do way too much FORMCHECKBOX Feel guilty/worthless FORMCHECKBOX Impulsive behavior FORMCHECKBOX Can’t think or concentrate FORMCHECKBOX See or hear things that may not be real FORMCHECKBOX Thoughts of death or suicide FORMCHECKBOX Suspect or believe things that may not be real FORMCHECKBOX Often tense/unable to relaxLife Problems that Currently affect you: FORMCHECKBOX Excessive worry FORMCHECKBOX Problems/losses within my family FORMCHECKBOX Panic Attacks FORMCHECKBOX Problems/losses among my friends/community FORMCHECKBOX Afraid/unable to leave home FORMCHECKBOX Educational problems FORMCHECKBOX Extreme unreasonable fears FORMCHECKBOX Occupational problems FORMCHECKBOX Intense fear of social situations FORMCHECKBOX Housing problems FORMCHECKBOX Can’t prevent repetitive thoughts FORMCHECKBOX Financial/economic problems FORMCHECKBOX Can’t prevent repetitive behaviors FORMCHECKBOX Can’t get adequate health care FORMCHECKBOX Intrusive, upsetting memories of past event FORMCHECKBOX Problems with the law, legal system FORMCHECKBOX Always on guard/never feel safe FORMCHECKBOX Body overreacts to “stress” FORMCHECKBOX Destructive/violent thoughts or behaviors FORMCHECKBOX Discipline problems at work FORMCHECKBOX Attempts to hurt, harm, or mutilate self FORMCHECKBOX Careless, high-risk behavior FORMCHECKBOX Anger outburstsGeneral Medical HistoryDo you have a Primary Care Physician? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesName:____________________________Phone Number:________________________Date of Last Physical Exam: ______________________Date of Last Laboratory Work: ____________________Do you suffer from any of the following general medical problems? FORMCHECKBOX Chest Pain FORMCHECKBOX Cancer FORMCHECKBOX Heart Attack FORMCHECKBOX Lung Disease FORMCHECKBOX Coronary Artery Disease FORMCHECKBOX Asthma FORMCHECKBOX Rheumatic Fever FORMCHECKBOX Emphysema FORMCHECKBOX High/Low Blood Pressure FORMCHECKBOX Chronic Cough FORMCHECKBOX Stroke FORMCHECKBOX Bronchitis FORMCHECKBOX Heart Palpations FORMCHECKBOX Pneumonia FORMCHECKBOX Heart Surgery FORMCHECKBOX Tuberculosis FORMCHECKBOX Pace Maker Implant FORMCHECKBOX Shortness of breath FORMCHECKBOX Neurological Disorders FORMCHECKBOX Arthritis FORMCHECKBOX Seizures FORMCHECKBOX Muscle Cramps FORMCHECKBOX Epilepsy FORMCHECKBOX Muscle Stiffness FORMCHECKBOX Fainting FORMCHECKBOX Weakness FORMCHECKBOX Vertigo/Dizziness FORMCHECKBOX Tremors FORMCHECKBOX Motor Difficulties FORMCHECKBOX Numbness FORMCHECKBOX Serious Head Injury FORMCHECKBOX Difficulty Walking FORMCHECKBOX Recurring Headaches FORMCHECKBOX Uncontrolled Movements FORMCHECKBOX Kidney Disease FORMCHECKBOX Liver Disease FORMCHECKBOX Diabetes FORMCHECKBOX Jaundice FORMCHECKBOX Thyroid Disease FORMCHECKBOX Hepatitis FORMCHECKBOX Hormone Problems FORMCHECKBOX Stomach Ulcers FORMCHECKBOX Fever or Sweats FORMCHECKBOX Nausea/Vomiting FORMCHECKBOX Blood Disease FORMCHECKBOX Unusual Diet FORMCHECKBOX Anemia FORMCHECKBOX Abdominal Pain FORMCHECKBOX Bruise Easily FORMCHECKBOX Skin Rash FORMCHECKBOX Nose Bleed FORMCHECKBOX Skin Ulcer/Lesion FORMCHECKBOX Sexually Transmitted Disease FORMCHECKBOX Glaucoma FORMCHECKBOX HIV FORMCHECKBOX Visual Spots FORMCHECKBOX Sexual Difficulties FORMCHECKBOX Double Vision FORMCHECKBOX Gynecological Problems FORMCHECKBOX Hearing Problems FORMCHECKBOX Prostate Problems FORMCHECKBOX Speaking Problems FORMCHECKBOX Memory Problems FORMCHECKBOX Sinus or Nasal Problems FORMCHECKBOX Early Fatigue FORMCHECKBOX Recurrent Infection of any kind FORMCHECKBOX Daytime Sleepiness FORMCHECKBOX Depressed Immune System FORMCHECKBOX Difficulty Sleeping FORMCHECKBOX Recent Trauma FORMCHECKBOX Concentration Problems FORMCHECKBOX OtherDo you take any prescription medications for your general medical problems? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please list: ____________________________________________________________________Do you take over the counter medications or herbal supplements? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please list: ____________________________________________________________________Are you allergic to any medications? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please list medications and allergic reactions: ______________________________________ __________________________________________________________________________________Have you undergone any surgical procedures? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, list the surgical procedure with the date(s) of surgery: _________________________________________________________________________________________________________________Do you have problems with chronic physical pain? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesRate average pain level (Circle one):1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 (worst)Have you ever suffered a severe head injury with loss of consciousness or concussion? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please describe: _______________________________________________________________Have you ever had a seizure? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesAlcohol, Drug and Tobacco Use FORMCHECKBOX Check if noneAlcohol: Current use:____________Date of last use:____/____/____Past use:____________Problems related to use (Legal, Financial, Health, Relationship)? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please list: ____________________________________________________________________Was treatment required? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please describe: _______________________________________________________________Illicit drug and/or prescription drug abuse:SubstanceDate of Last UseProblems related to useTreatment RequiredBenzodiazepines (Valium, Xanax, Ativan) FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes FORMCHECKBOX (0)No FORMCHECKBOX (1)YesCaffeine FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes FORMCHECKBOX (0)No FORMCHECKBOX (1)YesMarijuana FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes FORMCHECKBOX (0)No FORMCHECKBOX (1)YesCocaine FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes FORMCHECKBOX (0)No FORMCHECKBOX (1)YesDesigner Drugs (Club, Drugs: G, X) FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes FORMCHECKBOX (0)No FORMCHECKBOX (1)YesHallucinogens(LSD, Mushrooms) FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes FORMCHECKBOX (0)No FORMCHECKBOX (1)YesInhalants(Gasoline,Glue, Aerosol) FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes FORMCHECKBOX (0)No FORMCHECKBOX (1)YesMethamphetamines(Speed, Ice, Ritalin) FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes FORMCHECKBOX (0)No FORMCHECKBOX (1)YesOpiates/Methadone(Vicodin, Oxycontin, Heroin) FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes FORMCHECKBOX (0)No FORMCHECKBOX (1)YesOther FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes FORMCHECKBOX (0)No FORMCHECKBOX (1)YesTobacco Use: FORMCHECKBOX (0)No FORMCHECKBOX (1)Yes Amount per day:________________Social HistoryWhere were you born? ___________________________Where did you grow up? __________________________Did your parents stay together while you were growing up? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf no, how old were you when they separated? _______________Father’s occupation while you were growing up: _________________________Mother’s occupation while you were growing up: _________________________How many siblings do you have? FORMCHECKBOX None_____ Brothers_____ SistersWere there any complications at your birth (premature birth, major medical problems)? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please describe: _______________________________________________________________Any problems in your early development (learning to walk, talk, etc)? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please describe: _______________________________________________________________Did you suffer from any major illnesses/injuries while you were growing up? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please describe: _______________________________________________________________Are you/were you a victim of any form of physical/sexual/emotional abuse? Physical Abuse FORMCHECKBOX (0)No FORMCHECKBOX (1)YesAge of occurrence:_______Sexual Abuse FORMCHECKBOX (0)No FORMCHECKBOX (1)YesAge of occurrence:_______Emotional Abuse FORMCHECKBOX (0)No FORMCHECKBOX (1)YesAge of occurrence:_______What is your highest level of education? _________________________________________________Are you currently employed? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf yes, where?______________________________________________________________________Are you currently involved in a romantic relationship? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesSpouse’s/partner’s first name:_________________________How long have you been together?_____________________How would you describe your relationship?_________________________________________________________________________________________________________________________________What is your spouse’s/partner’s occupation?_______________________Have you been involved in any previous significant intimate/romantic relationships? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please describe: _______________________________________________________________Do you have any children? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesNames & Ages:_____________________________________________________________________What are some things you enjoy doing (hobbies, sports, past times)? _______________________________________________________________________________________________________________________________________________________________________________________________Have you ever been convicted of any crimes, incarcerated in prison, or placed on probation? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please describe: _______________________________________________________________Do you belong to a particular religion or spiritual group? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, what is your level of involvement: ________________________________________________Family HistoryIs there any history of obesity, eating disorder, other mental illness or substance abuse among your blood relatives? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf yes, please describe below:Fathers Side:Mothers Side:Siblings:Social SupportsIs there anyone you trust or confide in during times of trouble? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesName Supports: ___________________________________________________________________Do you have any religious ties or involvement in a church? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, please describe: _______________________________________________________________Current Living SituationDo you live in a FORMCHECKBOX House FORMCHECKBOX Apartment FORMCHECKBOX Manufactured Home FORMCHECKBOX Other FORMCHECKBOX Own or FORMCHECKBOX RentDo you live alone? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf not, who else lives with you?________________________________________________________Do you have plans to move in the near future? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesIf so, where: _______________________________________________________________________Do you have any pets? FORMCHECKBOX (0)No FORMCHECKBOX (1)YesList:______________________________________________________________________________ ................
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