Eating Disorders Survey - Khalifeh

This is a survey designed to find out about your experiences with eating. It is pretty thorough. You can save and return to the survey if you need to take a break.

1. What is your name? *This question is required.

2. What led you to seek treatment now?
*This question is required.

3. Have you been in residential or intensive outpatient treatment in the last month?

Describe your symptoms (eating patterns and other behaviors) in the past four to six months. *This question is required.

4. Tell us about your diet. *This question is required.

a. What is a typical breakfast?
b. What is a typical lunch?
c. What is a typical dinner?
d. What kind of snacks do you eat?

5. What previous eating disorder treatment have you had? *This question is required.If you have had any eating disorder treatment please fill in the information.

Presenting Problem
Name of Program
Dates
Outcome
Meetings/Sponsor

6. Please list your current eating disorder clinicians.

Space Cell	Name	Phone number
Therapist	Name	Phone number
Psychiatrist / Other MD	Name	Phone number
Dietician	Name	Phone number
Other	Name	Phone number

8. When was your last complete physical exam visit? *This question is required.

9. What is the date of your most recent labs? *This question is required.

10. Put a check mark next to any medical problems that you have. *This question is required.

11. Have you had an EKG lately? If so, when and where? *This question is required.

12. When was your last dental exam? *This question is required.

13. Have you had any dental problems? *This question is required.

14. When was you last menses? *This question is required.

If you are taking birth control, what date did you start? *This question is required.

17. Do you have any allergies? If so, please list them. *This question is required.

18. Please list any past surgeries. *This question is required.

19. Please list any current or past diagnoses (medical). *This question is required.

20. Please list your current med(s) & the doses. *This question is required.

21. How many hours of sleep do you get per night? *This question is required.

22. Please check the boxes that apply. Are you experiencing any trouble: *This question is required.

Falling asleep
Staying asleep

23. Is your sleep restful? *This question is required.

24. Has your sleep pattern changed at all recently? *This question is required.

If your sleep pattern has changed, please describe the change. *This question is required.

Do you purge after binge-eating only or after all meals? *This question is required.

Copy of When was the first time you restricted? Please tell us more about when this behavior started (frequency, patterns, and the time of your life). *This question is required.

Eating Disorders Survey - Khalifeh - v2

Initial Assessment Survey