Recent admission to ER related to psychiatric emergency Recent arrest for domestic violence Restraining order pending Deterioration of family, social or intimate relationships Promiscuous / Dangerous sexual activity DUI Section 4: Prior Mental Health Hospitalization History Have you ever been treated at a psychiatric hospital or a psychiatric unit in a medical hospital? Yes No If yes: Date of Admit, How long were Facility Name Reason Month/Year you there? Are you currently the care of a Yes No Psychiatrist? If yes, how long have you been their care? Date of last visit Name of Psychiatrist Telephone Number Are you currently under the care of a Yes No Therapist? If yes, how long have you been under their care? Date of last visit Name of Therapist Contact information EATING DISORDER ASSESSMENT Has your weight ever been a concern to you, your family or your doctor? Yes No
Recent admission to ER related to psychiatric emergency Recent arrest for domestic violence Restraining order pending Deterioration of family, social or intimate relationships Promiscuous / Dangerous sexual activity DUI Section 4: Prior Mental Health Hospitalization History Have you ever been treated at a psychiatric hospital or a psychiatric unit in a medical hospital? Yes No If yes: Facility Name Reason Date of Admit, Month/Year How long were you there? Are you currently the care of a Psychiatrist? Yes No If yes, how long have you been their care? Date of last visit Name of Psychiatrist Telephone Number Are you currently under the care of a Therapist? Yes No If yes, how long have you been under their care? Date of last visit Name of Therapist Contact information EATING DISORDER ASSESSMENT Has your weight ever been a concern to you, your family or your doctor? Yes No