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FAMILY AND SOCIAL HISTORY: <br /> How many children are in your family of origin? Wh t number are you? <br /> Do you believe that you have a good support system? Yes No <br /> If so, do you confide in them about your problems? Yes No <br /> What areas are stressful in your life? (finances,job career, relationship, health, school, etc.) <br /> Have you ever been in trouble legally? Yes No <br /> If so, describe what the situation was: <br /> Do you have any present or past difficulties with: <br /> Shoplifting Yes No Drug use Yes I'10 <br /> Gambling Yes No Compulsive shopping Yes No <br /> Compulsive sexual behavior Yes No Alcohol use Yes No <br /> Describe: <br /> Have you ever been involved in a weight loss program (i.e., Weght Watchers, etc.) If so, please identify them: <br /> PSYCHIATRIC HISTORY: <br /> Have you ever received therapy/counseling before? Yes No <br /> Have you ever been prescribed psychiatric medication (i.e., antidepressant)? Yes No <br /> If yes, please list medication and describe length of time taken and purpose: <br /> Have you ever been hospitalized for psychiatric problems? Yes No <br /> 2 <br />