EDRC INITIAL PATIENT ASSESSMENT - University Of Florida

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EDRCINITIAL PATIENTASSESSMENTUpdated: July 19, 20121

Department of PsychiatryEating Disorder Recovery CenterInitial AssessmentPATIENT INFORMATIONNAME IN FULLFMAGEDATE OF BIRTHTODAY’S DATEADDRESSCITYCOUNTYSTATEZIP CODEHOME TELEPHONE NUMBERWORK TELEPHONE NUMBERCELL NUMBERMARITAL STATUSOCCUPATIONEMPLOYERREASON FOR APPOINTMENTREFERRED BY/HOW DID YOU HEAR ABOUT USCOMPLETE IF PATIENT IS A MINORMOTHER’S NAMEFATHER’S NAMECUSTODYLIVES WITHBoth ParentsMotherFatherOtherBoth ParentsPARENT’S/CONTACT’S TELEPHONE NUMBERMotherFatherOtherTELEPHONE NUMBER FOREMERGENCY CONTACTNAMERELATIONSHIP TO PATIENTHOME TELEPHONE NUMBERWORK TELEPHONE NUMBERADDRESSCITYSTATEZIP CODECONTACTSPRIMARY CARE PHYSICIANSPECIALTYLAST APPOINTMENTCITYSTATEPHONE NUMBERPSYCHIATRISTCITYLAST APPOINTMENTSTATEHOW LONG HAVE THEYTREATED YOU?HOW LONG HAVE THEYTREATED YOU?PHONE NUMBERTHERAPISTLAST APPOINTMENTCITYSTATEHOW OFTEN DO YOU MEET?DO YOU FIND IT HELPFUL?IF NOT CURRENTLY IN THERAPY, HAVE YOU BEEN IN THE PAST?IF SO, WAS IT HELPFUL?HOW LONG HAVE THEYTREATED YOU?PHONE NUMBERNUTRITION THERAPISTLAST APPOINTMENTCITYSTATEPHONE NUMBERHOW OFTEN DO YOU MEET?DO YOU FIND IT HELPFUL?IF NOT CURRENTLY IN THERAPY, HAVE YOU BEEN IN THE PAST?IF SO, WAS IT HELPFUL?2HOW LONG HAVE THEYTREATED YOU?

Medical HistoryMEDICAL PROBLEMS for which you are being treated:PROBLEMDOCTORHOW TREATED1.2.3.4.5.6.7.8.SURGERIES you have had:SURGERYWHEN1.2.3.4.5.6.7.8.MEDICATIONS and over-the-counter pills you are taking currently:NAME OF MEDICATIONDOSAGEHOW OFTEN TAKEN1.2.3.4.5.6.7.8.ALLERGIES:Are you allergic to any medications?YesDRUGNoPROBLEM1.2.3.4.5.Do you have any food allergies?YesNoIf so please list:3If so please list:

Psychiatric Medication History (check meds used in ranil (clomipramine)YesAmbien (zolpidem)YesCelexa (citalopram)YesAtivan (lorazepam)YesCymbalta (duloxetine)YesBromam (bromazepam)YesDesyrel (trazodone)YesBuSpar (buspirone)YesEffexor XR (venlafaxine)YesHalcion (triazolam)YesElavil (amitriptyline)YesKlonopin (clonazepam)YesLexapro (escitalopram)YesLibrium (chlordiazepoxide)YesLuvox (fluvoxamine)YesLunesta (eszopiclone)YesNardil (phenelzine)YesRestoril (temazepam)YesNorpramin (desipramine)YesRohypnol (flunitrazepam)YesPamelor (nortriptyline)YesTranxene (clorazepate)YesParnate (tranylcypromine)YesValium (diazepam)YesPaxil (paroxetine)YesXanax (aprazolam)YesProzac (fluoxatine)YesOther:Remeron (mirtazapine)YesMood StabilizersSarafem (fluoxetine)YesAbilify (ariprazole)YesSerzone (nefazodone)YesDepakote (valproate)YesSymbyax (fluoxetine/olanzapine)YesGeodon (ziprasidone)YesTofranil (imipramine)YesLamictal (lamotrigine)YesWellbutrin (bupropion)YesLithiumYesZoloft (sertraline)YesNeurontin (gabapentin)YesOther:Risperdal (risperidone)YesOther:Seroquel (quetiapine)YesOther:Tegretol (carbamazepine)YesAddiction MedicationsTopamax (topiramate)YesSuboxone/ SubutexYesTripleptal (oxcarbazepine)YesCampral/ Naltrexone/ VivitrolYesZyprexa derallYesOther MedicationsConcerta (methylphenidate)YesOther:Dexedrine (dextroamphetamine)YesOther:Focalin tera (atomoxetine)Yes4

Current Medical ConcernsCheck all that applyCardiovascularHeart problemsRequiring medication?Chest painsRacing heart/skippingHigh blood pressureRequiring medication?Chest tightnessShortness of breathHigh cholesterolRequiring medication?High triglycerides Requiring medication?Feel tired all the timeDiabetesDiabetes - Type I or II Requiring medication?Pre-diabeticElevated blood sugar?Gestational diabetesAge of Diagnosis?Hypoglycemia (low blood sugarThyroid nalGallbladder problemsRemoved?Stomach ulcersRequiring medication?Heartburn Daily?Nocturnal?RegurgitationRequiring medication?DiarrheaRequiring medication?ConstipationRequiring medication?RespiratoryAsthmaLast attack?Bronchitis # of times in past 2 yearsIs it recurring?Pneumonia # of times in past 2 yearsBlood clots in lungsSmokerStarting age?When did you stop?Smokeless tobaccoSnoreWake up gasping or with a smothered feelingMusculoskeletalLocationMildModerate SevereHip painKnee painAnkle painFeet painBack painNeck painArthritisFemales Only - Menstrual HistoryAre you currently menstruating?YesNoHave never menstruatedDate of last menstrual cycle Average weight fluctuation during menstrual cycleAs you lose weight do you cycles become irregular?YesNoAge began: Approximate weight at time of first menstruation:Approximate height when began:Are you taking birth control pills/patches/injections?Do you have PMS?YesNoYesNoIf yes, please describe5

Family and Social HistoryHave you ever experience any of the following?FAMILY:SOCIAL (in comparison to your peers did you feel):Death of a parentIsolationDeath of other loved one or close friendExcessively picked on or bulliedLife threatening illness in immediate familyExcessive shynessSeparation from a parent for a monthPoor peer relationshipsParent’s separation/divorceIllegal behaviorLoss of home through natural disasterFamily financial problemsSELF:Parent with substance abuse problemDelayed speechSignificant conflict with parentsDelayed motor developmentFoster careChronic illnessObesityABUSE/TRAUMA:Physical abuseSCHOOL:Sexual abuseAcademic problemsVerbal/Emotional abuseBehavior problemsNeglectLearning problemsRapeSchool failure/dropoutOther traumatic eventAre you currently a student?YesIf yes, please explain:NoHighest grade level you completedWhat grades did you make in school?What is your occupation/career? How long have you worked in this capacity?What, if any, legal problems have you had?What stresses are in your life now?What is your current living situation?Describe your social support system:Describe how your eating disorder is affecting your life:Are you currently married?YesNoHow many children do you have?How many times have you been married?Their ages:For women: How many times have you been pregnant?6How did you deliver?

Psychological HistoryPSYCHIATRIC or SUBSTANCE ABUSE treatment history:INPATIENT - WHEREDATESREASON1.2.3.4.5.OUTPATIENT – WHO TREATED(please include counseling/therapy)DATESREASON1.2.3.4.5.Have you ever attended AA/ NA/ Alanon/ Alateen or OA meetings?YesNoHave you been treated or diagnosed with any of the following:DepressionAnxietyFor the past few weeks have you felt:Have you ever been diagnosed with an anxiety disorder?(circle or check any that apply)Check all that apply Down or sad? Obsessive Compulsive Disorder (OCD) Had trouble sleeping? Generalized Anxiety Disorder (GAD) Problems concentrating? Social Anxiety/ Social Phobia Felt restless? Panic Disorder Felt worthless or guilty? Post-Traumatic Stress Disorder (PTSD) Had thoughts of hurting yourself?I would you describe yourself as an anxious person? Had thought of killing yourself?Bipolar DisorderFor the past few weeks have you felt:(circle or check any that apply) Distractibility Irritability Felt very powerful or entitled Engaged in increased risk taking behavior (sexualpromiscuity, spending money, dangerous activities) Spoke rapidly Felt as though your mind was racing Didn’t’ need to sleep for several daysHave you ever had any Suicide Attempts?YesNoI worry a lot about everyday things?YesNoI have obsessive thoughts related to anything specificYesNoI have any ritualistic activities (Checking locks repeatedly,washing hands repeatedly?)YesNoYesNoHave you ever heard voices when no one was around or seen things others have not seen?Do you feel you have special powers or abilities?YesNoNoDo you feel that others are following you, stealing from you or trying to hurt you?Do you feel others can control your thoughts or actions?YesYesYesNoPlease answer the following:How many drinks do you need to feel a buzz/”high”?Are you or others concerned with how much you drink?Do you need a drink in the morning?Do you have periods of time you don’t remember associated with your drinking?Have you ever blacked out from drinking?Have you tried to cut down your drinking?7NoYesNo

Please check which substances you have used in your lifetime:CurrentPastDate of PastDate oflast n inePropoxyphene/DarvonSleeping pillsInhalantsNitrous oxideIV drugsHeroinEcstasyLSDMushroomsGHBPCPKetamine (special “K”)RohypnolPlease Fill Out To The Best Of Your KnowledgeDo you weigh yourself?YesNoHow tall are you? ft inHow often?BMI:Current weight? lbsHow many calories do you need to maintainyour current weight?Desired weight? lbsHow many calories do you need to maintainyour ideal weight?How many calories do you eatdaily?Highest weight? lbsFor Office Use OnlyBMI:When?For Office Use OnlyLowest weight?HAMWI:lbsWhen?What contributed to this?What contributed to this?For Office Use OnlyBMI:Has anyone ever told you need to lose weight?YesNoIf yes, who and when?Has anyone ever told you need to gain weight?YesNoIf yes, who and when?Check to indicate which of your family members:Are “overweight”:YesNoIf yes, who and when?Try to eat healthy:YesNoIf yes, who and when?Try to control weight:YesNoIf yes, who and when?Have an eating disorder:YesNoIf yes, who and when?What is your family’s attitude about health/ weight?8

EATING PATTERNSHow hungry do you let yourself get: (not at all) 0---1---2---3---4---5---6---7---8---9---10(so much you get cramps)Describe what hunger feels like to youDescribe what fullness feels like to youHow do you know when to quit eatingCheck any of the following that describe your eating patterns recently:Eat 1 meal a dayEat 2 meals a dayEat 3 meals a dayEat less than othersEat more than othersEat “normally”Eat snacks between some mealsEat snacks between all mealsOvereat most of the dayOvereat some of the dayRestrict amount of food intakeRestrict type of food intakeEat more than intended in one sittingFeel out of control when eatingEat when I get hungryEat when not hungryEat in response to boredomEat in response to stressEat in response to depressionEat in response to anxietyEat in response to lonelinessEat in response to habitEat in response to angerEat in response to self-rewardEat in response to PMSEat in response to comfortEat in response to habitEat in response to external cuesInduce vomitingUse laxativesUse diureticsUse Ipecac syrupEat in secretHide foodBinge eatFeel guilty after eatingKeep a food journalEat slower than othersEat faster than othersEat standing upEat with othersEat aloneDo you have foods that you do NOT eat/drink?Red ther:Fried foodsSugar productsCarbohydrates(pasta, rice, and bread)Other:WaterRegular sodaDiet sodaJuicesOther:Which food could you NOT do ie/CakeRiceIce CreamPastaOther:Other:MeatEggsPizzaBreadFried t are your favorite foods?What beverages do you drink?waterwhole milkskim milkregular sodadecaf coffeeregular teasweet teaunsweetened tea2% milk1% milkdiet sodaregular coffeedecaf teajuiceOthers:Number of fast food visits per week:Do you eat uncontrollably at times?If yes, describe?YesNoIf yes, age(s):Have you ever been diagnosed with an eating disorder?YesNoIf yes, what and when?9

Dieting HistoryHave you ever tried to control your weight?YesNoIf yes, age at first attempt: years Your height at that time: Your weight at that time:Why did you go on the diet?Which diets have you tried:Weight WatchersNutri/SystemJenny CraigLA Weight LossRichard SimmonsSlimfastMetabolifeAtkinsHCG DietThe ZoneSouth BeachLow Carb dietSugar Busters dietFood PyramidDiabetic dietLiquid DietOptifastBody For LifeFit For LifeMedifastMayo Clinic dietPritkin dietRaw dietBlood Test dietNegative Calorie dietCider Vinegar dietWhat has been your most successful diet?Why do you suppose this was the case?Which diet pills have you tried:Fen-phenDex-fen-phenRedux (dexfenfluramine)Fastin (phentermine)AdipexIonaminOby-trimPondimin (fenfluramine )Tenuate (diethylpropion)DospanSanorex (mazindol)MazanorDidrexWellbutrin (bupropion)Beverly Hills dietScarsdale DietHollywood 48 hour dietCelebrity dietThe Grapefruit dietCabbage soup dietMediterranean dietSubway dietFastingCaveman dietLow Caloriehow many calories a dayOther diets:Meridia (sibutramine)Xenical (orlistat)Stimulants/Amphetamines(eg. Ritalin, Adderall)DexedrineEphedrineEphedraMa HuangCaffeineGuraranaBontril anolamine (PPA)Chromium r PillsDiet TeasMetabolifeXenadrineChitosanHerbalife diet pillsThyroid medicationOther:Activity/Exercise HistoryWhat is your regular activity level?Minimally activeSomewhat activeModerately activeVery activeExtremely active(very sedentary, rarely leave house)(light housework, gardening, walking on errandsor while working)(exercise 1-3 times a week, walking for exercise)(exercise 3 or more times a week, e.g. aerobics,running, swimming, weight training, cycling)(daily vigorous exercise)Do you have any physical conditions that limit your ability/safety to exercise?YesNoIf yes, describe:What is your favorite activity?What is your favorite exercise?How many days a week do you exercise? How many times a day? How many hours per day?10

Check the figure you think you look like Now:Check the figure you would most like to look like in the Future:11

Weight Watchers Food Pyramid Beverly Hills diet Nutri/System Diabetic diet Scarsdale Diet Jenny Craig Liquid Diet Hollywood 48 hour diet

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