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4212 J24. What are your future work or school goals? Have you ever been in trouble legally? ❑Yes ❑ No If so,describe the si:uation: Do you have any present of past difficulties with shoplifting? ❑Yes ❑ No If so,describe the situation: Do you have any present or past difficulties with gambling? ❑Yes ❑ No Do you have any present or past difficulties with compulsive shopping? ❑Yes ❑ No — — — — Have you ever been involved in a weight loss program(Weight Watchers, etc.)1)❑Yes ❑ No If so, please identify them: Does anyone in your family have a history of weight concerns? ❑Yes ❑ No, If so,who? PSYCHIATRIC HISTORY Have you ever received therapy/counseling before? ❑Yes ❑ No If so, p ease describe why and with whom. Have you ever been prescribed psychiatric medication(antidepressant,ADD medication,etc.)? ❑Yes ❑ No If yes, please list medication and when, and why you take them: Have you ever been hospitalized? ❑Yes ❑ No If so,why? Do you have any history of suicide attempts? ❑Yes ❑ No If so, please describe the situation: Have any family members had the following? If so,what is their relationship to you? ❑ Depression: ❑ Anxiety: ❑ Eating Disorder: ❑ Bipolar Disorder/Manic-depression: ❑ Obsessive-compulsive Disorder: ❑ Alcohol/drug problems: ❑ Suicide attempts: ❑ Psychiatric Hospitalizations ❑ Other mental health/psychiatric problems(please specify): CHEMICAL/ALCOHOL HISTORY- _ How often do you drink alcoholic beverages? ❑ Never ❑ Monthly ❑ Weeky ❑ Daily __—._-----_—_—.— ----..-- How often do you use illicit drugs? ❑ Never ❑ Monthly ❑ Weekly ❑ Daily Please list what drugs you have used: What best describes your caffeine intake? ❑ Never ❑ Monthly ❑Weekly ] Daily ...................._..._...... . . What best describes your nicotine intake? ❑ Never ❑ Monthly ❑ Weekly ] Daily Page 2 of 3