The Basics

This screening is for:

MyselfMy child/loved oneMy patient

First Name (only) of the person being screened:

Age Group:
—Please choose an option—6-9 years10-12 years13-15 years16-18 years19-22 years23+ years

Weight and Eating Concerns

In the past six months, has there been:

Lost a lot of weight (more than 10lbs)Lost a little weight (less than 10lbs)Gained a lot of weight (more than 10lbs)Gained a little weight (less than 10lbs)Not sure, but there's been a noticeable changeWeight has stayed about the same

Feels unhappy with how body looks:

Yes, most of the timeSometimesNo, usually okay with body

Sees self as bigger than others say:

YesSometimesNo

Skips meals or limits food intake:

Yes, oftenSometimesNo, eats regularly

Food and Exercise Behaviors

When considering the past 3 months, check any that apply:

Exercises even when sick, injured, or should be doing other thingsEaten large amounts of food at once and felt unable to stopMade self throw up or used laxatives/diet pills to control weightSpends a lot of time thinking about food, calories, or nutritionAvoids certain foods or has strict food rulesNot really interested in food or eatingTakes medications differently than prescribed to control weightWorries something bad will happen if eating (not related to gaining weight)None of these apply

Physical Symptoms

Check any experienced in the past 3 months:

Dizziness or faintingFeeling cold all the time when others are comfortableConstantly exhausted even with enough sleepHair falling out or getting thinnerMissed/Irregular menstrual period (if applicable)Noticed blood when throwing upHeart racing or feeling dizzy when standing upSwelling in hands, feet, or faceNone of these apply

Feelings and Thoughts

Check any experienced in the past month:

Feels need to be perfectOften feels stressed out or overwhelmedFelt sad or down most daysWorries a lot/often fearfulHas thoughts or habits that can't be controlledNeeds to be in control of everythingDifficulty sleepingMood changes quickly throughout the dayMood changes (up or down) persist for days or weeksNone of these apply

Safety Concerns

In the past month:

Hurt self on purpose (like cutting, scratching, or burning)Had thoughts about suicidePreviously tried to end lifeWished not to be alive anymoreNone of these apply

Who Should We Reach Out To?

Your Name:

Relationship to patient:
—Please choose an option—SelfParentGuardianSpouse/PartnerHealthcare ProviderOther

Email:

Phone Number: