Family History Assessment. Client Name: Date: Name: Circle One: Father Mother Stepmother Stepfather. Occupation: Highest Grade Completed/Degree:
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1 Family History Assessment Client Name: Date: Name: Circle One: Father Mother Stepmother Stepfather Married: YES/NO Number of Years: Divorced: YES/NO Number of Years: Separated: YES/NO Number of Years: Widowed: YES/NO Number of Years: Occupation: Highest Grade Completed/Degree: Describe your leisure activities (hobbies, sports, movies, TV, etc.): Please indicate if you, or any member of your family, either currently or in the past have experienced any of the following: Name Relationship Current or Past? Workaholism Depression Alcoholism Drug Abuse/Addiction Suicide Attempt/Thoughts Obesity Binge Eating Anorexia Nervosa Bulimia Nervosa Psychiatric Hospitalization Extreme Mood Swings Sexual Abuse Insomnia
2 * NOTE: In the following section, if the tense is wrong (e.g. your daughter/son is no longer living at home), please cross out present tense and write in past tense. For example, change does to did. A. Eating/Diet History Does your family currently have set mealtimes? Describe how you believe your family experiences mealtime: Describe mealtime (discussion, conflicts, atmosphere, who was/wasn t regularly present, etc.): Has this changed from the past? If yes, how? Are certain foods restricted in your household? If yes, describe: What was restricted? Why were they restricted? _ When were certain foods restricted?
3 Have members of your family dieted? If yes, describe: Did you or how did you teach your children regarding nutritious eating? B. Misc. Information Is appearance important in your family? Explain: Is high achievement in academics, work, sports, etc. emphasized by any family members? Describe: Describe any behavioral problems in childhood with your children (especially your daughter/son): Who usually does the disciplining of the children? Is this different from methods used in your upbringing? Explain:
4 Did you raise your daughter/son with any religious and/or spiritual beliefs? Explain: Describe the relationship you have with your daughter s/son s mother/father: Describe the relationship you have with your current spouse (if he or she is other than your daughter s/son s parent): _ Describe your relationship with your own mother: Describe your relationship with your own father: Have you ever been in therapy? If yes, please explain reasons for seeking treatment: How long were you in therapy? Are you currently in therapy? What was the outcome of the therapy?
5 Please describe any events you consider significant in the family history, including your background, your own family of origin and current family members (Information may include stressors such as marriage/divorce in family; victim of sexual/physical assault; moving to a new location; financial disaster; death of a relative or close friend; arrest or illegal incident; loss of job, new job; birth of child; separation or engagement; serious decline in health of family member; major accident or physical condition): Describe any problems with your daughter s/son s birth: Describe any developmental disturbances in childhood (developmental delays or prolonged illnesses, habits, anything that stands out as different or unique): Are there any educational or learning problems? If yes, explain: Describe the significant events and your feelings regarding your daughter s/son s life in the various stages below: a) Pregnancy and Birth:
6 b) Years 0-5: c) Elementary School Years: d) Middle School Years: e) High School Years: f) Years 18-25: g) Years 26-35: h) Years 36-45:
7 Describe your daughter/son prior to the onset of her eating disorder: When did you first notice a change in your daughter s/son s eating/grooming behavior/body condition? Describe: Describe the relationship you have with your daughter/son: Has this changed? If yes, in what way(s)? When did you start noticing any change? Describe: How would your daughter/son describe her relationship with you?
8 What would your daughter/son like to change about you? What would you like to see happen in your daughter s/son s treatment? (i.e what are your goals for her?) What do you think your daughter s/son s goals for treatment are? Have you tried to resolve problems on your own, prior to seeking treatment? If so, how? Any other comments you think might be helpful?
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