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Eating Disorders Survey - Khalifeh - v2

Initial Assessment Survey

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.
3. Have you been in residential or intensive outpatient treatment in the last month?
4. Tell us about your diet. *This question is required.
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.
6. Please list your current eating disorder clinicians.
Space Cell NamePhone number
Psychiatrist / Other MD
10. Put a check mark next to any medical problems that you have. *This question is required.
22. Please check the boxes that apply. Are you experiencing any trouble: *This question is required.
23. Is your sleep restful? *This question is required.
24. Has your sleep pattern changed at all recently? *This question is required.