Eating disorder self-assessment form — Central region

This form is for people in Wellington, Wairarapa, Manawatū-Whanganui and Hawke's Bay.

Please complete all questions and try to answer as fully as you can. Click 'submit' when you have finished. Someone from the central region eating disorder service (CREDS) will contact you once we have received your form.

General information

Are you a New Zealand resident
Do you or any members of your family who are supporting you have a hearing impairment?

Contact details

A copy of your responses in this form will be sent to your email provided above for your records. 

Preferred way for us to contact you
If we need to leave a phone message, tick which kind of message you are comfortable for us to leave
If possible, would you like to receive appointment reminders?

Next of kin

Have you had previous contact with CREDS?
Are you still having periods?
Are you on a contraceptive pill?

Your diet and eating habits

Are you limiting what you eat?
Are you trying to lose weight?

Describe what you eat in a normal day. (If each day is very different, just give some examples of type and amounts of food.)

Binge eating

Do you sometimes eat large amounts of food?
Do you eat constantly during the day?

Purging

Do you ever make yourself sick/vomit?
Do you ever use laxatives?

Your history

Do you have any other physical health issues?

Alcohol and drugs

Support services

Thank you for completing this self-assessment form. Make sure you click on 'Submit' below.