| Simply
click on the appropriate button then, when you have answered all of
the questions, click the Total button. You can print this form
and manually apply the values shown to the right for each answer. |
| 1.
How has your mood been lately as compared to your normal state? |
unhappy |
average |
very
happy |
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| 2.
How is your sleep pattern? |
don't
sleep well |
okay |
no
problem |
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3. How much
transition or change is occurring in your life?
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major
changes |
minor
changes |
few
changes |
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| 4.
How is your health? |
many
problems |
excellent
health |
few
problems |
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| 5.
How are your relationships with friends, family, spouse? |
very
unhappy |
okay |
very
content |
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| 6.
Do you have trouble expressing your needs and feelings and saying no
when you don't feel like doing something? |
yes,
definitely |
sometimes |
never! |
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| 7.
How is your sex life? |
very
poor |
okay |
excellent |
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| 8.
Is your sexual behavior healthy and satisfying? |
unhealthy |
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healthy |
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| 9.
Are you comfortable with your sexual orientation? |
no |
unsure |
yes |
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| 10.
Do you have problems with sexual/life issues (such as concerns about
having children, fertility, pregnancy, birth control, or abortion)? |
difficulties |
sometimes |
none |
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| 11.
Have you noticed problems with your memory? |
forgetful |
okay |
perfect
memory |
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| 12.
Do childhood memories or lack of them cause you any distress? |
often |
unsure |
no |
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| 13.
Do you accept the way that you look and feel about your body? |
hate
it! |
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love
it! |
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| 14.
Are you taking time out for yourself? |
no
time |
sometimes |
often |
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| 15.
Do you have excessive feelings of anxiety, fear, or distressing
phobias? |
regularly |
sometimes |
never |
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| 16.
Are you having occupational, school problems, or problems taking care
of your family? |
yes,
problems |
some |
none |
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| 17.
Are there any stressful situations occurring in your life? |
high
stress |
some |
low
stress |
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| 18.
Are you or someone close to you faced with a life-threatening illness? |
yes |
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no |
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| 19.
How has your energy state been lately compared to your normal state? |
large
change |
some |
no
change |
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| 20.
Do you find it difficult to understand and express your feelings? |
very
much so |
sometimes |
never |
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| 21.
Do you find yourself repeating behavior patterns that are unhealthful
or that are causing you distress? |
often |
rarely |
never |
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| 22.
Do you have trouble staying in a committed relationship even though
you desire intimacy? |
yes,
problems |
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no
problem |
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| 23.
Do you find yourself losing your temper often? |
often |
rarely |
never |
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| 24.
Do you feel that eating is a major focus in your life? |
very
important |
so-so |
not
at all |
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| 25.
Do you feel that you provide adequately for your family and/or for
yourself? |
no |
sometimes |
yes |
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| 26.
Do you have problems with emotions changing in cyclical or
unexplainable ways? |
severe |
rarely |
never |
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| 27.
Have you ever been raped, physically abused, beaten, or otherwise
sexually assaulted? |
yes |
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no |
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| 28.
Would you like to learn more about yourself and why you are the way
that you are? |
very
interested |
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not
interested |
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Totals: |
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