Adult Questionnaire

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Adult Questionnaire

ADULT QUESTIONNAIRE

DATE:

PHONE NUMBER:

EMAIL:

FULL NAME:

AGE

SEX

DO YOU HAVE INSUR-ANCE?YESNO

WHERE DID YOU LEARN ABOUT US?

WHAT KIND OF PROBLEMS DO YOU FACE?

SINCE WHEN?

WEIGHT:

HEIGHT:

HAVE YOU LOST WEIGHT IN THE PAST?

HOW MUCH?

IN WHAT WAYS?

DO YOU HAVE EPISODES OF BINGING?

HOW MANY EPISODES PER DAY?

PLEASE DESCRIBE AN EXAMPLE OF A BINGING EPISODE:

DO YOU TAKE LAXATIVES?

DO YOU VOMIT?

DO YOU HAVE GYNECOLOGICAL PROBLEMS?

HOW DO YOU FEEL ABOUT YOUR BODY?

HAVE YOU BEEN OBSERVED BY A PSYCHIATRIST OR A PSYCHOLOGIST IN THE PAST?

I confirm the accuracy and legitimacy of the above data which I filled in and I sign.

Name and Signature

(Note: This completed form will be given to you for signature when you visit ANASA at your 1st appointment)

I confirm that I am over 18 years old

I have read the Notice on the collection and processing of personal data and by submitting my details, I declare my consent.

Subsequently, the clinical team of ANASA will receive the completed questionnaire, evaluate it and the Secretariat of DC ANASA will call you to schedule the 1st appointment with a specialist of our Center.

Thank you very much and we will contact you soon!