Parent History - Eating Disorder - Child or Teen Eating/Weight Concern Assessment Form

Dear Parent
Below is a list of questions which asks about your view of your child. Thank you for taking the time to carefully complete this form. I am very interested in your perspective. Your responses will help me formulate a treatment plan, as well as help me use the time we spend together most efficiently.

Today’s Date

Name of Child or Teen

Date of Birth

Name of Person Completing Form

Relationship to Child/Teen

Age of Child

Gender

Current Height

Current Weight

Highest Weight Ever Attained

Amount of Weight Loss (if applicable)

Grade

Current School

Please give a brief description of your reason for seeking treatment for your child/teen.

Please describe in detail the concerns you have about your child’s eating and eating habits?

When did you first become concerned about her food and eating? What were the changes in her eating habits that you first noticed. Did those change further as time went on?

Has any medical professional such as a pediatrician or endocrinologist or gastrointestinal doctor been concerned about your child’s eating habits or weight or height?

Yes No

If yes please explain.

Please list any professionals who have been involved in your child’s care for this issue. Please list their type of specialty and date range when your child saw this professional.

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Has your child seen a therapist and or a psychiatrist in the past for any other issue?

Yes No

If so please list the name of the professional, reason for the visit and time frame of treatment.

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Is he currently on any psychiatric medications?

Yes No

Please list name of medication and dosage

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Has he tried other psychiatric medications in the past?

Yes No

Please list name of medicine, reason and response

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Does your teen engage in any notable mealtime habits such as cutting the food in small pieces, chewing slowly , taking a long time to eat, wiping off the food with a napkin ?

Yes No

If Yes, please describe

Has your teen ever been hospitalized or attended a day program for her eating issues.

Yes No

If yes please list in chronological order the programs and hospitalizations and dates of stay.

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Does your child vomit ( not including times when he has a stomach bug or virus) ?

Yes No

If yes please describe when that happens and if it appears to be a pattern or related to any factors that you can identify?

Does your child have any body image issues?

Yes No

If yes, please describe

Have you noticed that your teen spends a lot of time checking herself in the mirror? Or checking parts of her body ?

Yes No

If Yes, please describe

Do you believe your child has any concerns about gaining weight?

Yes No

If yes, please describe

Have you heard your teen expressing any comments about her body or others peoples body size?

Yes No

If Yes, please describe

Has your child or teens mood changed since the time you noticed a change in her eating pattern?

Yes No

Please describe

Is your child participating in any sports currently?

Yes No

If so which sport and how often?

Did your teen participate in sports last year?

Yes No

If so what and at what frequency?

Is your child exercising currently?

Yes No

If so how often and for what duration? Do you have any concerns that the exercise is excessive or compulsive in nature?

Developmental History:

Length of pregnancy

Please describe any medical issues or complications during pregnancy, labor, and delivery

Please describe any delays in your child’s development or aspects of his/her development that you think would be important for me to know.

Does your child have any fears or phobias

Yes No

If so please describe below

Family Composition:

Are the child’s parents divorced?

Yes No

If yes what is the custody and visitation agreement? Please indicate if there is an ongoing custody dispute.

If yes please describe child’s current living arrangements and the composition of his primary household.

Please list child’s siblings:

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How does your child get along with his/her siblings?

School History:

Regular Education

Special Education

reason

Was your child evaluated either by the school system or privately?

Yes No

If so please provide a copy of any evaluations that you have.

Files

Add file

Please upload a file

Please describe any special services received in school

How does your child get along with peers? Please describe below. Is he/she outgoing or more reserved? Does he/she have close friends, is part of a group of friends. Does your child complain of being picked on or bullied by peers. Do others see your child as “beating to a different drummer? ”Does your child bully others? Has this changed over time?

History of self-injury: Has your child engaged in any type of self-injury such as cutting him or herself? Does she or he engage in any other behaviors such as pulling hair, picking scabs?

Yes No

Please describe if any

Has your child ever been admitted to a psychiatric hospital or participated in a outpatient psychiatric program?

Yes No

Please explain

Do you believe your child has a problem with drug or alcohol use?

Yes No

Please describe if any

Has your child ever been abused or molested?

Yes No

Please describe if any

Medical History:

Primary doctor’s name

Phone #

Please Describe

Allergies (to food or medication)

Current Medications (include prescription and over-the-counter medications and vitamins):

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Medical Hospitalizations or Emergency Room Visits

Family Psychiatric History: Please report history of psychiatric illness in all family members, including parents, siblings, grandparents, aunts, uncles, and cousins.

Depression

Relative

Treatment (if known)

Bipolar disorder

Relative

Treatment (if known)

Anxiety disorder

Relative

Treatment (if known)

Schizophrenia

Relative

Treatment (if known)

Other psychotic disorder

Relative

Treatment (if known)

ADHD

Relative

Treatment (if known)

Behavior problems

Relative

Treatment (if known)

Learning disorder

Relative

Treatment (if known)

Autism spectrum disorder

Relative

Treatment (if known)

Substance abuse

Relative

Treatment (if known)

Eating Disorder

Relative

Treatment (if known)

Please list any Relevant Family Medical History

Anything else about your child that you feel is important for me to know?

Your information will be encrypted.

Parent History - Eating Disorder

Developmental History:

Family Composition:

School History:

Medical History:

Miriam Wolosh Ph.D.

Psychologist NJ License 3381