Process - Physician - Fraser Health Authority

Current Height:Lowest Wt:Highest Wt:Client’s desired weight:Current Wt:Age:Age:/ /Date obtained: (mm/dd/yyyy)Vital SignsTemp ______________ Resp _____________________Pulse Sitting _______________________BP Lying __________________________Pulse Standing ______________________BP Standing ________________________Eating Disorder Related Behaviours:Restricting: Yes No History of RestrictingDaily intake: less than 1 meal/day 1 meal/day 2 meals per day or morePurging: (over the past 3 months)Vomiting Yes No Frequency: daily 2-3x / week less than once / weekHistory of purging, if not purging currently Yes NoExercise – hours per week 0-3 4-10 10-15 15-20 20-30 30 +Laxatives: Yes No History of Laxative AbuseType(s) used:Frequency / number per day: 1 to 10 10 to 20 more than 20Other Purging Methods:Diuretics Thyroid Medications IpecacAppetite Suppressants Insulin manipulation Other _______________________Binge Eating (Objectively large amount of food within any 2 hour period; experience loss of control)Yes No Frequency: daily weekly monthly2