Name
*
Including preferred pronouns (i.e. she, he, they):
First Name
Last Name
Email
*
Phone
(###)
###
####
Date of birth:
Occupation
How did you hear about me?
Have you ever worked with a therapist or psychiatrist? (Yes/No) If yes, who/when/why?
Have you ever worked with a nutritionist/health coach/dietitian? (Yes/No) If yes, who/when/why?
MEDICATIONS AND SUPPLEMENTS: List medications you are currently taking, including vitamin/mineral supplements:
Describe what fullness feels like to you:
How do you decide what to eat?
How do you know when to stop eating?
Do you usually eat when you get hungry? (Yes/No)
Do you often eat when you are not hungry? (Yes/No)
Can you tell the difference between physical hunger and "emotional hunger"? (Yes/No)
Have you ever been diagnosed with an eating disorder? (Yes/ No) If yes, please describe:
How would you describe your eating patterns?
MOVEMENT: Do you currently get regular physical activity? (Yes/No) Describe:
Do you enjoy it?
Describe past history with exercise/movement:
Do you consider yourself a compulsive or over exerciser? (Is it hard not to exercise, even if you are tired, sick or not in the mood?) (Yes/No)
Has your weight changed significantly in the past 2-6 months? (Yes/ No) If yes, please describe:
Do you know your highest adult weight? Age?
Do you know your lowest adult weight? Age?
How often do you weigh yourself?
What are three words you would use to describe how you feel in your body?
Check the things you do to “check” your body:
Are you on birth control pills or hormone replacement therapy? (Yes/ No)
OTHER HEALTH CONCERNS: List any medical conditions you would like me to be aware of:
GASTROINTESTINAL CONCERNS: Do you have problems with:
If you checked yes, please describe:
LIFESTYLE/DAY TO DAY CARE: What percentage of your day is focused on food, weight, or body image?
What is your current stress level on a scale from 0-10, with 10 being high?
What is your usual stress level?
What causes you the most stress currently?
What helps you cope with stress?
How many hours do you usually work daily?
How many hours do you sleep daily?
What do you do to relax?
How often do you drink alcohol? How much per occasion?
How often do you use recreational drugs? Describe:
ADVERSE LIFE EVENTS/TRAUMA: Over the course of your life, have you had any experiences that you would like me to know about now?
Many people experience adverse life events that impact their sense of well-being and safety, including and not limited to religious/spiritual trauma, oppression, bullying, harassment, abandonment, neglect, medical traumas, accidents, military service, historical trauma, and/or physical/emotional/sexual abuse or assault.
Have you experienced weight-related discrimination or stigma from healthcare professionals, partners, family members or in a workplace setting?
What else would you like me to know about you?
What do you hope to achieve as a result of working with me?
