Eating Disorder Assessment - Full

Rationale of Appointment [Reason for appointment] (only include if explicitly mentioned, e.g. initial assessment, follow-up, admission planning) [Members of medical team present] (only include if explicitly mentioned) [Patient and relatives/friends present] (only include if explicitly mentioned) [Date of referral and source of referral] (only include if explicitly mentioned) Physical Measurements & Observations [Weight] (only include if explicitly mentioned) [Height] (only include if explicitly mentioned) [BMI] (if explicitly mentioned, record directly. If not explicitly mentioned but both weight (kg) and height (m) are given, calculate BMI = weight ÷ (height²). Otherwise leave blank.) [ideal weight range, provide weights for BMI 19 - 25] (if explicitly mentioned, record directly. If not explicitly mentioned but both weight (kg) and height (m) are given, calculate BMI = weight ÷ (height²). Otherwise leave blank.) [Change since previous weight, including rate of change in kg/week] (only include if explicitly mentioned) [Heart rate] (only include if explicitly mentioned) [Blood pressure] (only include if explicitly mentioned, include sitting/standing variation if available) [Oxygen saturations] (only include if explicitly mentioned) [Capillary glucose] (only include if explicitly mentioned) [SUSS test results] (only include if explicitly mentioned) [Blood test results with dates] (only include if explicitly mentioned) History of Presenting Complaints [Current issues and reasons for visit] (only include if explicitly mentioned) [Associated symptoms with details] (only include if explicitly mentioned) Past Medical & Psychiatric History [Past psychiatric diagnoses, treatments, hospitalisations] (only include if explicitly mentioned) [Chronic medical conditions] (only include if explicitly mentioned) Weight History [Dieting history] (only include if explicitly mentioned) [Weight cycling history] (only include if explicitly mentioned) [Premorbid/usual weight] (only include if explicitly mentioned) Body Image [Body checking behaviours] (only include if explicitly mentioned) [Body avoiding activities] (only include if explicitly mentioned) [Body image distortion] (only include if explicitly mentioned) Disordered Eating / Eating Disorder Behaviours [Restricting intake] (only include if explicitly mentioned) [Binge eating] (only include if explicitly mentioned) [Overeating] (only include if explicitly mentioned) [Self-induced vomiting] (only include if explicitly mentioned) [Exercise patterns/compulsivity] (only include if explicitly mentioned) [Rumination] (only include if explicitly mentioned) [Chewing and spitting] (only include if explicitly mentioned) [Laxative or diuretic use] (only include if explicitly mentioned) [Diet pill use] (only include if explicitly mentioned) [Misuse of prescribed medication] (only include if explicitly mentioned) [Other purging behaviours] (only include if explicitly mentioned) [Night eating] (only include if explicitly mentioned) Eating Behaviour [Hunger and fullness cues] (only include if explicitly mentioned) [Food rules or fear foods] (only include if explicitly mentioned) [Allergies or intolerances] (only include if explicitly mentioned) [Vegan/vegetarian diet] (only include if explicitly mentioned) Nutrition Intake [Wake-up time and eating habits] (only include if explicitly mentioned) [Breakfast] (only include if explicitly mentioned) [Morning snack] (only include if explicitly mentioned) [Lunch] (only include if explicitly mentioned) [Afternoon snack] (only include if explicitly mentioned) [Dinner] (only include if explicitly mentioned) [Evening snack] (only include if explicitly mentioned) [Meals per day] (only include if explicitly mentioned) [Fluid intake] (only include if explicitly mentioned) Physical Activity Behaviour [Current activity] (only include if explicitly mentioned) [Relationship with physical activity] (only include if explicitly mentioned) Menstrual History [Age of onset] (only include if explicitly mentioned) [Date of last period] (only include if explicitly mentioned) [Usual cycle length] (only include if explicitly mentioned) [Cycle regularity] (only include if explicitly mentioned) [Menstrual symptoms] (only include if explicitly mentioned) [Contraception use] (only include if explicitly mentioned) Gut / Bowel Health [Gut and bowel habits] (only include if explicitly mentioned) Medications [Current medications, names, doses] (only include if explicitly mentioned) Family History [Family psychiatric or medical history] (only include if explicitly mentioned, specify relationship and condition) Personal and Developmental History Pregnancy and Birth [Complications during pregnancy or birth] (only include if explicitly mentioned) [Birth weight] (only include if explicitly mentioned) Infancy and Early Childhood [Developmental milestones: language, motor, coordination] (only include if explicitly mentioned) [Social and emotional development: attachment, comfort, play, emotional display] (only include if explicitly mentioned) [Early difficulties: developmental delays, tantrums, separation anxiety] (only include if explicitly mentioned) School Years [Educational performance: achievements, learning difficulties] (only include if explicitly mentioned) [Social relationships: friendships, bullying experiences] (only include if explicitly mentioned) [Emotional/behavioural issues: concentration, behaviour, mood] (only include if explicitly mentioned) Adolescence and Adulthood [Significant life events or stressors] (only include if explicitly mentioned) [Social and occupational functioning] (only include if explicitly mentioned) [Substance use history: alcohol, drugs] (only include if explicitly mentioned) Social History [Occupation and education level] (only include if explicitly mentioned) [Current Substance use: smoking, alcohol, recreational drugs] (only include if explicitly mentioned) [Social support] (only include if explicitly mentioned) [Finacial situation] (only include if explicitly mentioned) [Forensic history] (only include if explicitly mentioned) Mental Status Examination [Appearance] (only include if explicitly mentioned) [Behaviour] (only include if explicitly mentioned) [Speech] (only include if explicitly mentioned) [Mood] (only include if explicitly mentioned) [Affect] (only include if explicitly mentioned) [Thoughts] (only include if explicitly mentioned) [Perceptions] (only include if explicitly mentioned) [Cognition] (only include if explicitly mentioned) [Insight] (only include if explicitly mentioned) [Judgment] (only include if explicitly mentioned) Risk Assessment [Suicidal ideation, intent, or self-harm risk] (only include if explicitly mentioned) [Medical complications and treatment concordance] (only include if explicitly mentioned) [Protective factors and social support] (only include if explicitly mentioned) [Access to lethal means] (only include if explicitly mentioned) Diagnosis [Diagnosis and ICD-11 criteria, provide list of specific diagnostic criteria fulfilled] (only include if explicitly mentioned) [Psychological scales/questionnaires] (only include if explicitly mentioned) Treatment Plan [Planned investigations] (only include if explicitly mentioned) [Medication plan: changes, continuations, discontinuations] (only include if explicitly mentioned) [Psychotherapy plans] (only include if explicitly mentioned) [Family meetings, collateral information, psychosocial interventions] (only include if explicitly mentioned) [Follow-up appointments and referrals] (only include if explicitly mentioned) Safety Plan [Safety plan steps in crisis] (only include if explicitly mentioned) Do not generate any details, assessments, plans, interventions, evaluations, or continuing care information that are not explicitly provided in the transcript, contextual notes, or clinical note.