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Details of this error have been logged.Submission Success!Patient InformationName*Social Security Number*Date of Birth*AgeMarital Status*SingleMarried / PartneredSeparatedDivorcedWidowedGender Identity*Cisgender ManCisgender WomanNonbinaryTransgenderNot ListedPrefer Not to AnswerSexual Orientation*AsexualBisexualGayHeterosexualLesbianPansexualQueerQuestioningNot ListedPrefer Not to AnswerReligious Preference*AtheistAgnosticBuddhistChristianHinduMuslimJewishNot ListedPrefer Not to AnswerHome Phone*Mobile Phone*Email Address*Mailing Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherZip Code*Insurance InformationInsurance Subscriber NameSocial Security NumberDate of BirthPhone NumberEmail AddressAddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherZip CodePrimary InsurancePrimary Insurance CarrierPhone Numberthe one providers should callID NumberGroup NumberSecondary InsuranceSecondary Insurance CarrierPhone Numberthe one providers should callID NumberGroup NumberGuarantor (Financially Responsible Party) InformationName*Social Security Number*Date of Birth*Phone Number*Email Address*Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherZip Code*General InformationHow did you hear about Carolina House?GoogleBingYahooFacebookPsychology TodayEDReferral.comOtherIf Other, please specify.Are you currently employed / in school?YesNoAre you having difficulties at work / school?FatigueTrouble FocusingMedical LeaveOtherPlease describe your difficulties at work/school.Have you ever served in the United States military (branch, details)?Are you held under a conservatorship or guardianship (conservator name, details)?If yes, will require filling out an extra form, and we will need a copy of the court order prior to admission.If you are an adolescent, are your parents divorced? (If yes, we will need a copy of the custody agreement.)YesNoDo you have any legal issues (details, parole, etc.)?Health InformationHeight (Feet)Height (Inches)Current Weightin poundsAmount of Weight Change (+/-) in the Last Six MonthsHighest Adult Weight (Outside of Pregnancy)in poundsAge When At This WeightLowest Adult Weightin poundsAge When At This WeightWeight CommentsIf you require a vegetarian diet, please provide details.Please list any food restrictions that you observe as part of your religion.Please list any food intolerances.AllergiesPlease list all of your food and non-food allergies. Medical documentation for food allergies is required.Allergy / ReactionRemovee.g., dogs / itchy eyes, sneezingAdd Another (19 remaining)Do you have medical documentation for these allergies?YesNoCurrent medications (prescribing physician, name of medicine, dosage, reason for use)?RemovePlease note: Some medications may be altered or withdrawn after your meeting with our medical team.Add Another (9 remaining)Eating Disorder HistoryFor the following section, please indicate your behaviors for the last 30 days. If you are currently in treatment, please answer regarding your behaviors before entering treatment.On average, how many days per week do you restrict your food?01234567How many calories do you limit yourself to each day?How long have you been actively restricting your food?Any additional details about your food restriction (if applicable)?What purging methods do you use?Diet PillsDiureticsEnemasLaxativesVomitingOtherPurging details, if applicable (days per week, times per day, how many diuretic/diet pills, etc.)?On average, how many times a week do you binge?01234567How long have you been actively bingeing?Describe a typical episode of bingeing (e.g., time of day, foods typically consumed, eating an extra meal).Do you binge at night (details)?On average, how many days per week do you exercise (for any length of time, including any sports practiced or consistent body movement that you might do for your employment)?01234567On average, how many minutes/hours per day do you exercise?Do you exercise at night?YesNoWhy do you exercise?EnjoymentOverall WellnessStrengthTo Compensate for Food ConsumedAny further details about your exercise?If you have ever attempted to control your eating in ways that have not been covered so far, please describe.e.g., 24-hour recall, chew/spit behavior, intestinal bypass, caffeine use, chewing gum or ice, substance abuseSubstance Abuse HistoryFill out below where applicable.Marijuana UseDate of Last Marijuana UseFrequency of Marijuana UseAverage Marijuana Use AmountCocaine/Crack UseDate of Last Cocaine/Crack UseFrequency of Cocaine/Crack UseAverage Cocaine/Crack Use AmountMethamphetamine UseDate of Last Methamphetamine UseFrequency of Methamphetamine UseAverage Methamphetamine Use AmountAmphetamine Use(e.g., Adderall)Date of Last Amphetamine UseFrequency of Amphetamine UseAverage Amphetamine Use AmountBarbiturate Use(e.g., Amytal, Nembutal, Seconal)Date of Last Barbiturate UseFrequency of Barbiturate UseAverage Barbiturate Use AmountHeroin UseDate of Last Heroin UseFrequency of Heroin UseAverage Heroin Use AmountPCP UseDate of Last PCP UseFrequency of PCP UseAverage PCP Use AmountHallucinogen UseDate of Last Hallucinogen UseFrequency of Hallucinogen UseAverage Hallucinogen Use AmountBenzodiazepene Use(e.g., Valium, Ativan, Xanax)Date of Last Benzodiazepene UseFrequency of Benzodiazepene UseAverage Benzodiazepene Use AmountInhalant UseDate of Last Inhalant UseFrequency of Inhalant UseAverage Inhalant Use AmountAlcohol UseDate of Last Alcohol UseFrequency of Alcohol UseAverage Alcohol Use AmountType of Alcohol UsedBeerWineLiquorOpiate UseDate of Last Opiate UseFrequency of Opiate UseAverage Opiate Use AmountSynthetics Use(e.g., Bath Salts, Ecstasy/MDMA)Date of Last Synthetics UseFrequency of Synthetics UseAverage Synthetics Use AmountOTC Medication Use(e.g., Cold/Cough Medication)Date of Last OTC Medication UseFrequency of OTC Medication UseAverage OTC Medication Use AmountSpecify OTC Medications UsedNicotine UseDate of Last Nicotine UseFrequency of Nicotine UseAverage Nicotine Use AmountMental Health HistoryDo you experience significant mood swings (details)?Do you exhibit periods of verbal or physical agression (directed inward/outward/both, details)?Have you ever been diagnosed with any of the following?An Anxiety DisorderBipolar DisorderDepressionObsessive-Compulsive Disorder (OCD)Post-Traumatic Stress Disorder (PTSD)Please give details on any of the above diagnoses.Please specify any other medical/clinical diagnoses you have.Are you currently having suicidal thoughts?NoI have passive suicidal thoughts (i.e., It would be easier if I ended my life.)I have active suicial thoughts (i.e., I'm thinking about ending my life.)Have you been suicidal in the past (how many times, details)?Are you currently engaging in self-harming behaviors (e.g., burning, cutting, hitting)?NoOnce per week2-3 times per week4-5 times per week6-7 times per weekMore than 7 times per weekHow long have you been actively self-harming, if applicable?Additional self-harming details (describe a typical episode, etc.)?Treatment InformationAre you currently in treatment?YesNoIf so, are you engaging in disordered behaviors in treatment?YesNoWhy have you contacted us now? Has something changed recently?How long have you had problems with food / eating disorder symptoms?Any periods of recovery during that time (please describe)?On a scale of 1-10, how motivated are you to receive treatment (10 being extremely motivated)?12345678910Comments About Your Motivation to Receive TreatmentOn a scale of 1-10, how much do you fear gaining weight (10 being extremely afraid)?12345678910Comments About Your Fear of Gaining WeightAre you able to commit to being safe while at Carolina House?YesNoIf you are unable to walk up and down stairs and shower/dress by yourself, please give details.If you suffer from any chronic pain, please provide details.Do you require any assistive devices (e.g., hearing aids, wheelchair) or a translator (please provide details)?If you are currently in a medical hospital or inpatient acute facility, are you eating solid food (details)?Please list any non-food items that you eat.Have you been treated by a therapist, primary care physician, dietitian, psychiatrist, or other medical specialist? Please specify name, location, type (Therapist, PCP, Psychiatrist etc.), dates seen, and reason for treatment.RemoveAdd Another (9 remaining)Have you ever been treated in an intensive outpatient program? Please specify name of program, dates of treatment, length of stay, and reason for treatment.RemoveAdd Another (9 remaining)Do you have an outpatient psychiatrist?YesNoIf admitting into IOP you will need your own outpatient psychiatrist.Have you ever been treated in a day treatment/partial hospitalization program? Please specify name of program, dates of treatment, length of stay, and reason for treatment.RemoveAdd Another (9 remaining)Have you ever been treated in a residential treatment program? Please specify name of program, dates of treatment, length of stay, and reason for treatment.RemoveAdd Another (9 remaining)Have you ever been in an inpatient (psychiatric) treatment program? Please specify name of program, dates of treatment, length of stay, and reason for treatment.RemoveAdd Another (9 remaining)Have you been in a medical hospital for reasons related to an eating disorder? Please specify name of hospital, dates of treatment, length of stay, and reason for treatment.RemoveAdd Another (9 remaining)Have you ever left any of the above facilities against medical advice (details)?How has your eating disorder affected you medically (e.g., tube feeding, refeeding, abnormal EKGs/cardiac problems, ER visits for fluids, fatigue, loss of menstrual periods, decreased bone density, difficulty concentrating)?What is your plan for aftercare (e.g., stay with Carolina House for step-down treatment, return to referring facility, transfer elsewhere)?Do you have any relationship dynamics or family circumstances that may impact your treatment?Are there any cultural, religious, or spiritual considerations we should be aware of?Is there anything that we haven't asked that you believe we need to know so that we can make the most appropriate treatment recommendations for you?
