Self-Health Assessment

MPEDC Intentional Arrival
Client Name:*
First NameLast Name
Session Date:*
MonthDayYear
What I need to leave behind from my day: *
Reflection on how present my Healthy Self was during my day:
Healthy Self*

1 2 3 4 5
1 is Mostly Absent, 5 is Mostly Present
What can I do better to bring Healthy self forward:*
Reflection on how present my ED Self was during my day:
ED self*

1 2 3 4 5
1 is Mostly Absent, 5 is Mostly Present
What can I do to better cope with my ED self:*
ED BEHAVIORS FROM TODAY:*
Restricted portion sizeLooked at old picturesLack of motivationSkipped a mealEmotionally ateIssues with partnerSkipped a snackRegurgitated foodFeels better overallDid not hydrateIssues at workIssues at homeOver portionedFeels stressedLess conflictAte beyond satietyDecreased intimacyBingedCommunication worseUsed caffeine to quell hungerMood swingsExercised for compensationChewed gum to quell hungerExercised on a rest dayAte in secretPurgedExercised beyond recommended amountThrew food awayDefeating self-talkBody checkedChewed and spitWeighed self
Explain:*
Recovery Focused Behaviors from Today:*
Followed meal planPracticed gratitudeIncreased variety with food choicesCommunicated with my doctorAsked for accountabilityMoved an item off my to do listAte with othersMaintaining progressPracticed flexibility when plans changedAnxiety decreasingFelt my feelingsReached out for helpMoving through griefLack of focus/organiz.Talked back to my ED voiceIncrease in motivationPlanned/Coped aheadBetter self-careCommitted to therapyIncreased understanding of partnerBetter work/leisure balanceDid not go longer than 3 hours without eating somethingPacked snacksTaking more responsibility for emotionsMore awareness of internal dialogBreaking self-defeating patternsTook medication as prescribedEstablishing better boundaries
Explain:*

Objectives & Progress
Objective 1:
Progress:
Objective 2:
Progress:
Objective 3:
Progress:
Notes:
Recommendations:
Continue Therapeutic FocusChange Treatment Goals / ObjectivesIncrease Frequency of SessionsDecrease Frequency of SessionsTerminate TreatmentOther
New treatment goals/approach:
Signature:
Should be Empty:

MPEDC Intentional Arrival