| Condition | Please circle | List Family Member |
| Alcohol/Substance Abuse | yes/no | |
| Anxiety | yes/no | |
| Depression | yes/no | |
| Domestic Violence | yes/no | |
| Sexual Abuse | yes/no | |
| Eating Disorders | yes/no | |
| Obesity | yes/no | |
| Obsessive Compulsive Disorder | yes/no | |
| Schizophrenia | yes/no | |
| Suicide Attempts | yes/no | |
| Other diagnosed mental health condition? | yes/no : which was— |