Clinical sheet Eating disorders , Eating disorders Clinics Institute of Psychiatry Medical School ain Shams University Hospital

1. DEPARTMENT OF NEUROPSYCHIATRY
WHO Collaborating Center
For Mental Health
Research & Training
Institute of Psychiatry
Founded By Prof. Ahmed Okasha
Ain Shams University Hospitals
Chairman, Prof. Ahmed Saad
Tel: (202) 24346702 – 24346918
Fax: (202) 24346702 – 24346742
Head of Eating Clinic : Prof. Heba Essawy
P.O. Box: 22 Dair El Malak – Cairo – 11657
FEEDING AND EATING DISORDER
CLINICAL SHEET
№:----------
Name : …………………………………………
Sex : M  F  Age : …………….. Date of birth : ………………….
Employment : …………………………………………………………………………………….
Address : …………………………………………………………………………………….
Marital Status : …………………………………………………………………………………….
Assessment Date : …………………………………………………………………………………….
Referral source : …………………………………………………………………………………….
Diagnoses:
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History of Present Illness (Psychiatric and Medical History):
……………………….……………………………………………………………………………………………..
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2. DEPARTMENT OF NEUROPSYCHIATRY
WHO Collaborating Center
For Mental Health
Research & Training
Institute of Psychiatry
Founded By Prof. Ahmed Okasha
Ain Shams University Hospitals
Chairman, Prof. Ahmed Saad
Tel: (202) 24346702 – 24346918
Fax: (202) 24346702 – 24346742
Head of Eating Clinic : Prof. Heba Essawy
P.O. Box: 22 Dair El Malak – Cairo – 11657
Social History (Living situation, family or career support, education, etc…):
……………………….……………………………………………………………………………………………..
……………………….……………………………………………………………………………………………..
……………………….……………………………………………………………………………………………..
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Effect of eating disorder on life: …………………………………………………………………………...
Amount of time spent thinking about weight, eating, eating concerns? : ……………………………………
Can they eat in front of others? ………………………… Who?: ……………………………….
Medications:
……………………….……………………………………………………………………………………………..
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Height and Weight
Height : …………… (m) ( / / ) % ile ………
Weight : ……………. (kg) ( / / ) %ile
BMI : ……………. (kg/ m2) ( / / )%ile
Lowest Past
Healthy Weight : ………………… Weight Range : …………………
Highest Past Weight : ………………… Goal Wt : …………………
Gain/Week : …………………
Eating Behaviour:
- Description of eating (restrictive patterns, dietary “rules”)
 Average/ day (now) – Breakfast, Snack, Lunch, Snack, Dinner, Snack
……………………….…………………………………………………………………………………………
 List of foods they will eat …………………………………………………………………………
……………………….…………………………………………………………………………………………
 List of foods they will not eat Food …………………………………………………………….
……………………….…………………………………………………………………………………………

3. DEPARTMENT OF NEUROPSYCHIATRY
WHO Collaborating Center
For Mental Health
Research & Training
Institute of Psychiatry
Founded By Prof. Ahmed Okasha
Ain Shams University Hospitals
Chairman, Prof. Ahmed Saad
Tel: (202) 24346702 – 24346918
Fax: (202) 24346702 – 24346742
Head of Eating Clinic : Prof. Heba Essawy
P.O. Box: 22 Dair El Malak – Cairo – 11657
 Allergies/intolerances: what food and what happens?....................................................................................
……………………….…………………………………………………………………………………………
 Vegetarian?........................................ Vegan?.............................................................................................
……………………….…………………………………………………………………………………………
 Intolerances (e.g. Lactose) ……………………………………………………………………………………………..
 Preferences ……………………………………………………….. ……………………………………………………
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- Purging
 Fluid loading: …………………………………………………………………………………………………..
 Purge: …………………………………………………………………………………………………………..
 How long after binge/eating? ………How?........................................................................................
 Times vomited …………………………………………………………....................................................
 Blood vomited…………….. How often? …………How much? …………………………………………..
Exercise:
 Type : Aerobics: ……….
Anaerobics: ……..
 Intensity : ……………………..
 Duration/24h : …………………….  Frequency : ……………………..
 Solitary : ……………………..  Effect of missing
exercing :
 Obligatory : …………………….. ………………….
Substance misuse (what, how much, when?)::
 Laxatives : ……………………..  Emetics : ……………………..
 Diuretics : ……………………..  Enemas : ……………………..
 Suppository : ……………………..  Amphetamines : ……………………..
 Spitting food : ……………………..

4. DEPARTMENT OF NEUROPSYCHIATRY
WHO Collaborating Center
For Mental Health
Research & Training
Institute of Psychiatry
Founded By Prof. Ahmed Okasha
Ain Shams University Hospitals
Chairman, Prof. Ahmed Saad
Tel: (202) 24346702 – 24346918
Fax: (202) 24346702 – 24346742
Head of Eating Clinic : Prof. Heba Essawy
P.O. Box: 22 Dair El Malak – Cairo – 11657
Binge Eating Behaviour:
*Frequency of binge
Eating over past 3 months (circle)
 < Once per night  2 x day
 < Once week  5-10 x day
 1-5 x week  10 x day
 Once a day
*Typical times and settings for binge eating
 Morning  Middle of Day  Evening
 Alone  Planned
 At home  Other place
Mood
Before: ……………….. During: ………………… After episodes: …………………
(1 = lowest; 10 = highest) (Circle)
Before
         
1 2 3 4 5 6 7 8 9 10
During
         
1 2 3 4 5 6 7 8 9 10
After
         
1 2 3 4 5 6 7 8 9 10
Experience loss of control?
 Yes : …………………………………………………………………………………………………..
 No : …………………………………………………………………………………………………..
 Not sure : …………………………………………………………………………………………………..

5. DEPARTMENT OF NEUROPSYCHIATRY
WHO Collaborating Center
For Mental Health
Research & Training
Institute of Psychiatry
Founded By Prof. Ahmed Okasha
Ain Shams University Hospitals
Chairman, Prof. Ahmed Saad
Tel: (202) 24346702 – 24346918
Fax: (202) 24346702 – 24346742
Head of Eating Clinic : Prof. Heba Essawy
P.O. Box: 22 Dair El Malak – Cairo – 11657
Attitudes towards weight and shape:
Level of self –criticism : …………………………………………………………………………….
Whole body & specific regions : …………………………………………………………………………….
Perceptions of shape : …………………………………………………………………………….
Frequency of weighing, weight preoccupations and intrusive thoughts:
……………………….……………………………………………………………………………………………..
Response to weighing:
……………………….……………………………………………………………………………………………..
Perception of others’ attitudes about patient’s weight:
……………………….……………………………………………………………………………………………..
Physical Signs and Symptoms Checklist:
Signs and Symptoms
 Agitation  Low body weight
 Irritability  Bradycardia
 Amenorrhoea  Dental erosion
 Oligomenorrhea  Dry skin
 Constipation  Yellow/ orange skin
 Abdominal pain  Oedema (specify):
 Abdominal bloating  Hair loss
 Cold intolerance  Hypotension
 Fatigue  Lanugo
 Weakness  Hypothermia
 Salivary gland hypertrophy
Physical Signs:
Temperature : ………………… Blood Pressure : …………………
Pulse : …………………
Bone Densitometry : ………………………….. Date : ..………………..
Pelvic Ultrasound : ………………………….. Date : ..………………..
ECG –QTc : ………………………….. Date : ..………………..

6. DEPARTMENT OF NEUROPSYCHIATRY
WHO Collaborating Center
For Mental Health
Research & Training
Institute of Psychiatry
Founded By Prof. Ahmed Okasha
Ain Shams University Hospitals
Chairman, Prof. Ahmed Saad
Tel: (202) 24346702 – 24346918
Fax: (202) 24346702 – 24346742
Head of Eating Clinic : Prof. Heba Essawy
P.O. Box: 22 Dair El Malak – Cairo – 11657
Estimated Nutrition Requirements:
Energy : ……………………………………………..……………………………………………………………
Protein : ……………………………………………..……………………………………………………………
Fluid : ……………………………………………..……………………………………………………………
Biochemistry:…………………………………………….. Date: ……………….
Blood tests:
 Full blood count (FBC),
 Electrolytes (UEC),
 Na
 K+
 cl
 Bicarbonate
 Liver function tests (LFTs),
 Glucose,
 Calcium, magnesium, and phosphate (mandatory in assessment if rehydration or re-feeding is planned).
 Urine analysis: …………………………………………………………………………………………………………