Screening sheet

Clinic code........................ Patient code...................... Date of birth ........

gender: 1 male
2 female

Diagnosed since.............. Date of the

Interview:..........

1. Clinical diagnosis according to DSM- IV.

1 anorexia nervosa (307.10)

restricting type
binge eating / purging type
2 bulimia nervosa (307.51)
purging type
nonpurging type
3 ED not other specified (307.50)
4 other:...............

Following DSM-IV criteria have been fulfiled:

ANOREXIA NERVOSA:

1 body weight under 15% or more of the normal weight

2 intense fear of gaining weight
3 distorted body image
4 the absence of at least three months consecutive menstrual cycles
5 repeated binge attaks
2. BULIMIA NERVOSA

1 repeated episodes of binge eating at last twice a week for three months
2 loss of control during eating
3 recurrent compensatory behaviour in order to prevent weight gain (induced
vomiting,
misuse of laxatives, diuretics, medications; fasting; excessive exercise)
4 self evaluation unduly influenced by body shape and weight

Eating Disorder Not Otherwise Specified

1. All of the criteria for Anorexia Nervosa, but regular menses.

2. All of the criteria for Anorexia Nervosa, but weight is in the normal range.
3. All of the criteria for Bulimia Nervosa, but the binge eating and
inappropriate compensatory mechanisms occur at a frequency of less than
twice a week or for a duration of less than 3 months.
4. The regular use of inappropriate compensatory behavior by an individual of
nomal body weight after eating small amounts of food (e.g., self-induced
vomiting after the consumption of two cookies).
5. Repeatedly chewing and spitting out, but not swallowing, large amounts of
food.
6. Binge-eating disorder: recurrent episodes of binge eating in the absence of
the regular use of inappropriate compensatrory behaviors

Patient included into the study:

1 yes 2 no

If no, please specify why: .

1 criterion 1 not fulfilled

2 criterion 2 not fulfilled,
3 criteria 3 and 4 not fulfilled
4 criterion 1 fulfilld only in the past
5 under the minimal age of admission