Medical History / Health Check / Anamnesis

Prepare yourself for the free intake. we kindly ask you to fill in the form below. This will give us a basic idea of who you are. You will need approximately 30 minutes. Take your time and answer the questions honestly. 

Name *
Name
+ country code (+0031 .... )
Example: 17 January 1985
Example: 169 cm + 65 kilo
Streetname (nr) + zipcode + city + country
Example: stomach pain, bowel problems, digestions problems, constipation, diabetes, pain, hair loss, heart arrhythmia, high or low blood pressure, bruises etc.
Example: Stress, no sleep, anxiety, panic attacks, depression, thoughts, worries etc..
If this is your first form of therapy? Please do not fill in anything if this is your first therapy, otherwise please fill in the names of people/organisations you went for help before.
Example: I hope he/she will be honest, treats me with respects, confronts me when needed, and shares her personal stories of recovery.
And are there any side effects? Or did you use any medication in the past?
If so, what kind of sport do you do and how many times a week?
If so, how often and when do you experience this?
Comorbidity: trauma, stress, anxiety or panic attacks, self-harm, autism, other personality disorder.. etc.  
If so, what do you use/take on a weekly basis?
Did you ever think of (or tried) to commit suicide?
Are you on your healthy (set point) weight right now?
What should you do (in all honesty) to improve your health?
Describe your breakfast + lunch + dinner + snacks and drinks (and other things in between as well)
May you not work/or go to school at the moment, please describe your most previous experience or activity.
Do you siblings/parents/partner? And with whom do you live now? (or alone)
What kind of eating disorder do you have? Anorexia, Boulimia, Binge Eating or a combination or something else? Please describe for yourself how you see it...
Who would you be and what would you do immediately?
BONUS QUESTION: Do you believe you can recover from your eating disorder?
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