Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Eating Disorder Screening Form
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Current Weight & Height
Weight History
Dieting & Food Preoccupation
Binge Eating Behavior
Purging & Compensatory Behaviors
Additional details
Exercise Patterns
Body Image Assessment
Dietary Patterns & Restrictions
Screening Score & Risk Level
Emergency Contact
Name
Relationship
Phone
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Signature
Date
Eating Disorder Screening Form template from formisoft.com. formisoft.com/intake-templates/eating-disorder-screening