Please provide details of any illness or other health-related concerns such as
1. Heart Disease (hypertension, etc)
2. Endocrine problems (thyroid, diabetes, etc)
3. Epilepsy (seizure disorder)
4. Pulmonary problems (bronchitis, asthma, pneumonia, etc)
5. Other
Please provide details of any mental health concerns such as 1. Eating Disorders (anorexia, bulimia) 2. Mood Disorders (depression/bipolar disorder, etc) 3. Anxiety Disorder 4. Suicide Attempt with Dates 5. Alcohol/Drug Treatments with Dates 6. Outpatient/Inpatient History (diagnosis, dates)