If your client has a history of eating disorders, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Diagnosis ?
       Anorexia Nervosa
       Bulimia Nervosa


   2.  Number of episodes ? 

       Date of last episode/recovery ? 


   3.  What is your client's current height and weight ?
       Height  
       Weight  


   4.  Has weight remained stable for at least one year ? Yes   No 

       If no, give details: 

   5.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   6.  Has your client been hospiltalized for treatment of an eating disorder ? Yes   No 

       If yes, give details: 


   7.  Does your client have a history of any of the following associated conditions ?
        Substance Abuse (alcohol or drugs)
        Personality Disorder
        Psychotic Disorder
        Suicidal Thought/Attempt



   8.  Has your client smoked cigarettes in the last 12 months ? Yes   No 


   9.  Does your client have any major health problems ? Yes   No 

       (example: cancer, etc.)

       If yes, give details: