2 Week Purchasing Recall 2017
Answers marked with a * are required.
We would like to get a general picture of any compulsive buying episodes you experienced over the last two weeks. Do not list necessary, healthy or routine buying episodes. List only those episodes that you consider to be compulsive or impulsive (felt driven, compelled, or a loss of control).

Be as specific as possible when listing the items you purchased: (ex: clothes, shoes, jewelry, purses, collectibles, crafts, books/magazines, music CD/tapes, greeting cards, nick knacks, electronics, appliances, furniture, DVD/VHS movies, video games, food/groceries, pet supplies, tools, household items/decorations, office supplies, toys, movie/game rentals, etc.). Also please indicate which items listed (if any) were purchased as a gift by writing “gift” beside that item.

First Name
Last Name: *
Please describe any compulsive shopping episodes you have had in the last two weeks:

Dates of Two Week Period: (dd -dd/mm/yyyy)

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