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• <br /> . itzli„.1 <br /> ADOLESCENT PERSONAL INFORMATION SHEET <br /> Name I Date of Birth i [ Age <br /> -___—^__ --- -.--- Grade/Year <br /> School in school I <br /> Cell I <br /> Phone <br /> Parents i <br /> Address <br /> Please list all of your immediate family members.(parents,brothers,sisters,etc.), <br /> NAME AGE i RELATIONSHIP TO YOU DOES HE/SHE LIVE IN YOUR HOME? <br /> I I ❑Yes ❑ No <br /> ❑Yes ❑ No <br /> ( ❑Yes ❑ No <br /> ❑Yes ❑ No <br /> El Yes ❑ No -- ___ _ <br /> ❑Yes ❑ No <br /> ❑Yes ❑ No <br /> ❑Yes ❑ No <br /> ❑Yes ❑ No <br /> i <br /> __ ) ❑Yes —0 No —. _ <br /> Does anyone else live in your home that isn't already listed? If so,please list their name,age,and relationship to you. <br /> What prompted you to have an Eating Disorder Assessment and what are your expectations? <br /> MEDICAL HISTORY ' ,,.„ <br /> Who is your primary health care provider? <br /> When was your last physical? <br /> Females only:do you have regular menses? ❑Yes ❑ No Date of last period: <br /> Do you have any significant health <br /> problems(diabetes, migraines)? ❑Yes ❑ No If yes, please explain: <br /> Do you take over-the-counter drugs <br /> (decongestants,Tylenol,etc)or vitamins ❑Yes ❑ No Please list: <br /> rula ? — --_-_-- � __-------_.._ ____ <br /> List any current prescriptions you take and +____._� _._______-_-___ <br /> the prescribing doctor. <br /> FAMILY AND SOCIAL HISTORY: <br /> _ <br /> Identify stressors in your life.(work,school,friends,etc.) -- .___�_ ____�._�.�___._____._____ <br /> Is there someone you can talk to about your problems? <br /> How would you describe your school life? <br /> _ <br /> Page 1 of 3 <br />