Patient’s Name: Date:  Full Address: City: State: Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip:   Age: DOB:  Parent’s Name (if applicable):  Parent’s or Patient’s Phone Number:  Insurance: Referral Source Name:   Full Address: City: State: Select a State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip:   Phone Number: OUTPATIENT PROVIDERS PCP Name: Phone Number:  Psychiatrist: Phone Number:  Therapist: Phone Number:  Nutritionist: Phone Number:  Current Weight: Height: Highest Weight:  Lowest Weight: Any recent change in weight: yes  no How much change in weight?    Is the change an increase or decrease? Over what period of time?   Less than 85% of IBW: yes  no BMI: Last time hydrated:   Pregnant: yes  no Last menses:    Onset:  Diabetic: yes  noCrohn’s Disease: yes  no Osteoporosis: yes  noVital signs (pulse below 50): yes  no Other major illness: Dates of last medical evaluation:    Dental problems:  How long has the eating disorder been active?   Is the patient’s PCP aware of the ED?   CURRENT DSM IV DIAGNOSIS (Please complete): Axis I: Axis II: Axis III: Axis IV: Axis V: GAF Current Medications: Is there a history of substance abuse?  yes  no 30 days sober?  yes  no Is there a history of trauma?  yes  no Please describe: Is the patient’s PCP aware of the ED?   Psychiatric/Medical: Emergency Room:  Suicidal ideation/attempts?   yes  no If yes, explain: Any psychotic features?   CURRENT ED BEHAVIORS: Restrict: yes  no Binge episodes/week: Purges per week: Purging Behaviors: Vomiting Laxatives Diet pills Diuretics Enemas  Ipecac Syrup Current activity level: Sports     Gym           Exercise Over the past two weeks, any of the following:  Heart palpitations Blood in vomit or stool Fainting/Dizziness Chest pain Unusual muscle cramps ALL FOOD EATEN IN THE PAST TWO DAYS: MEDICAL ISSUES: CURRENT LABS: BODY IMAGE: MOTIVATION FOR CHANGE: TREATMENT GOALS (Please complete): ADDITIONAL INFORMATION/COMMENTS: *Any missing / incomplete information can result in a delay of the admission process* 1525 River Oaks Road West, New Orleans, Louisiana 70123 * 504-734-1740 * 800-366-1740   © 2007 UHS All Rights Reserved | Disclaimer | Notice of Privacy Practices