Clinical Intake and Assessment Form
Friday—May 20, 2016
Patient Identification Information
Name: |
Anna M. Roux, maiden name Aubry |
Date of birth: |
November 13, 1989 |
Place of birth: |
Paris, France |
Sex: |
Female |
Age: |
26 |
Emergency Contact Information
Name: |
Matthias Roux |
Relationship: |
Spouse |
General Background
Occupation:
I tell people I am a dancer. I have not danced in years, though. I work as a cashier in a supermarket, but my real occupation is anorexia.
Marital Status: |
Married. |
Children: |
None. |
Yet. Hopefully, maybe, after this is all over?
I skip Ethnic Background, Family and Social History, Education, and Hobbies.
Physical Health
I feel fine, thank you.
Allergies: |
None. |
Last menstrual cycle: |
Unknown. |
I cannot remember.
Birth control? Contraceptive medication?
What for? And what for?
Weight and height: |
None of your business. |
Patient’s weight: |
88 lbs. |
|
Patient’s height: |
5' 4'' |
BMI: |
15.1 |
So I am a little underweight. So what?
Daily Habits
Tobacco:
No. I do not like the smell.
Alcohol:
A glass of wine, once a week on a Friday night.
Recreational drugs:
No.
Caffeine:
How else do you think I function on only three hours of sleep?
Number of meals eaten on a normal weekday:
Define the words “normal” and “meal.” I keep a few apples in my bag in case I get too hungry.
Number of meals eaten on a normal weekend day:
Why would that be different? Well, I do sometimes make popcorn in the microwave. Single serving. Nonfat.
Regular exercise routine: Yes.
Naturally.
Frequency: Every day.
Please describe:
I run, build strength, and stretch for two hours, every morning before 7:00 A.M.
What do you do to manage stress?
I run, build strength, and stretch for two hours every morning before 7:00 A.M.
Mental Health
Basic problem or concern: Difficulty eating certain foods.
Difficulty eating, period. Loss of interest in food, loss of interest in general.
Significant changes or stressors in recent history: None
that I have any interest in disclosing here.
Previous mental health diagnoses: None.
I said I feel fine.
Feelings of sadness?
Check.
Hopelessness?
Check.
Anxiety?
Check check.
Please check any symptoms experienced in the past month:
Restricted food intake.
Check.
Compulsion to exercise.
Check.
Avoidance of certain foods.
Check.
Laxative abuse.
Check.
Binge.
Check. A whole box of blackberries last week.
Self-induced vomiting.
Only with guilt. See above on blackberries.
Concerns about weight, body image, feeling fat.
Check. Check. Check.
Total weight lost over the past year:
Pass.
Lowest weight ever reached:
Pass again.
These questions are inappropriate.
Diagnosis
Anorexia nervosa. Restricting type.