Child Information Child's First Name (only) Age Group —Please choose an option—6-10 years10-13 years14-18 years Weight and Eating Concerns Has there been weight loss in the past 6 months? Less than 10 lbsMore than 10 lbs (or 5% of total body weight)I don't know but it seems like a lot to me Are there concerns about body image or fear of weight gain? YesNoUnsure Is there a pattern of avoiding meals or limiting food intake? YesNoUnsure Behaviors (Past 3 Months) Select all that apply: Excessive or compulsive exerciseEpisodes of eating large amounts of food with loss of controlSelf-induced vomiting or laxative/diuretic usePreoccupation with food, calories, or nutritionHighly restrictive or ritualistic eating patternsNone of the above Physical Symptoms Select all that apply: Dizziness or faintingAlways feeling coldExcessive fatigueHair loss or thinningNone of the above Parent/Guardian Contact Information Your Name Email Phone Number
