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Eating Disorder Program - Intake Form

Adolescent Health Service

North York General Hospital

This form is used for screening purposes and to help us triage patients for the Adolescent Eating Disorders Program. All patients need to have an assessment with our team, in order to further assess suitability for our program. Please note in order for us to triage and offer assessment appointments. We require the following:

-This form completed in full
-Current ECG (within 4 weeks)
-Current blookwork, CBC, and electrolytes (within 4 weeks)
as attachment or fax details to 416-635-2409.

Patient Information

Date of Referral: *
OHIP#: * - - -
Last Name: *
First Name: *
Sex: *
DOB: * Day: Month: Year:
Postal Code: -
Telephone (RES): * ( )- -
Mother's Name:
Work or Cell: ( )- -
Father's Name:
Work or Cell: ( )- -
Parent's Email:

Referring Physician/Healthcare Provider Information

First Name: *
Last Name: *
Primary Telephone: * ( )- -
Email: *
MD Billing#: *
Fax: * ( )- -
Family/Doctor Paediatrician: *


Presenting Problem(s):

Presenting Problems: *

Patient's Current Weight and Height


Present: * KG Date:
Select a date from the calendar.


Present: * CM Date:
Select a date from the calendar.

Orthostatic Vital Signs
(Lying and Standing)
(within 4 Weeks)
Please be aware that this referral is not complete without this information and the patient will not be offered an appointment.
Supine BP* HR* Date*
Standing BP* HR* Temp

Other History/Comorbitities:

Please indicate if a referral is also sent to another eating disorder program: *
If yes, which program:


Please send recent (within 4 weeks of referral) blood work (CBC, lytes), ECG, and growth charts to eating disorder clinic in order to complete the referral.

Please be aware that the referral is not complete without the patients growth curve or historial height + weight data. Without this we cannot offere them an appointment. Any Questions, please call intake 416-635-2400.

1: Please Select:*

2. Please Select:*

3. Any Additional Document(s)

Please fax all additional addendums to:
Attn: Intake
Child and adolescent eating disorders clinic
North York General Hospital
Fax: 416-635-2409