Personal Information
Name:
Age :
Date of Birth :
Telephone :
e-mail address :
Postal Address:

Marital status: Married Single Divorced Widowed
No. of Children and their ages:

What is your understanding of the difficulties you have with your relationship with food and your body image?

Please indicate occurrence and frequency of the following symptoms (e.g. daily, weekly, seldom, never):
Binge eating: daily weekly seldom never
Purging: daily weekly seldom never
Laxative abuse: daily weekly seldom never
Restrictive eating: daily weekly seldom never
Obsessive exercise: daily weekly seldom never

Please provide a brief history (onset and progress) of your eating disorder/difficulty:

Other areas of difficulty

Have you experienced (or are you currently experiencing) any of the following: (Please describe your experience
Depression:

Mood swings:

Anxiety:

Panic attacks:

Aggressive outbursts:

Self-mutilation: Do you ever have self-destructive feelings or feelings of wanting to hurt yourself (e.g. cutting)?

Do you experience overwhelming suicidal feelings?

Have you ever planned or attempted suicide? (Please specify)

Substance abuse: Do you ever try to escape though drinking or using drugs or over the counter medication?

Treatment

Have you been treated or hospitalised for your eating disorder or for any of the above? Please indicate where you were treated and duration of treatment.

Have you received a psychiatric diagnosis?

Is there a medical person (G.P. or psychiatrist, dietician) involved in your treatment?

What is the name and contact number of your psychiatrist. (Psychiatrist will only be contacted with your permission).

Are you on any medication?

Have you ever been in psychotherapy? (Please indicate type of therapy, therapist name and duration of treatment)

Could you describe any benefits you experienced in your therapy?

Which of your previous dietetic advisors (including all diet programmes, books etc.) were most helpful and why?

Current functioning

What work do you do? How are you coping at work?

Are you in a relationship? What are you relationships like in general (friends, family, partner?

How do you manage when you have to deal with painful feelings (e.g. if something difficult comes up in a relationship or in therapy)?

Have you had previous experienced of group therapy?

What are your personal objectives for the group?

Thank you your your submission.