Before beginning, please enter in your last name: 01:Do you have any of the following health concerns? trouble sleepingchange in weightget tired easilyloss of appetiteloss of strengthnone of the above 02:Do you have any of these skin problem?have rashesrecent loss of hairbreaking out in blemishesitchingnone of the above 03: Do you have any of these visual problems? change in visiontrouble seeing at nightblurred visionflashing lights in visionpain in eyesnone of the above 04: Do you have any of these hearing or problems with sense of smell? loss of hearingringing in earssinus problemschange in sense of smellearachesnone of the above 05: Do you have any of these problems? toothachesore gumssore throatchange in voicedifficulty swallowingdry mouthchange in sense of tastelosing teethstiff neckdry mouthneck is sore and tendernone of the above 06: Do you have any of these chest complaints? pain in chestdifficulty breathingfrequent coughdifficulty breathing during exerciseheartbeat seems irregularhigh blood pressurenone of the above 07: Do you have any of these digestive problems? frequent upset stomachfrequent nauseaburning in back of throatfrequently burp or belchhave a lot of gasfrequent stomach crampsconstipationdiarrhea or loose stoolsdifficulty swallowing foodoften use medicine to settle stomachdifficulty eating mealnone of the above 08: Do you have any of these problems? bruise or bleed easilyskin heals slowlyincreased appetiteoften thirstyexcessive sweatingdiscomfort with heat or coldnone of the above 09: Do you have any of these orthopedic problems? bone painjoint painmuscle painmuscle crampsfrequent back problemsback painchange in postureshoulder painwrist painelbow painankle painknee painhip painneck painnone of the above 10: Do you have any of these problems? muscle weaknesstwitching of musclesmuscle spasmstrouble walkingbalance problemstremors or shakingproblems with dropping thingstrouble walking up stairsnumbness or tingling in arms or legsblackouts or fainting spellsseizuresheadacheshaving trouble keeping track of timeforgetting thingshaving memory problemshearing unusual soundsseeing unusual thingshaving strange feelingsgetting confusedhaving trouble concentratinghaving trouble following a conversationnone of the above 11: Are you having any of these urinary problems? frequent urinationpainful urinationtrouble stopping urinationleak urinepain during intercoursechange in sexual performanceproblems with orgasm or ejaculationnone of the above 12: Do any of these apply to you? rarely exercisehave a poor dieteat at irregular timeshave not seen a doctor in yearshave not seen a dentist in the past yearI use tobaccoI use marijuanaI use cocaine or other recreational drugsfrequently use alcoholnone of the above 13: Do you have any of these in your personal history? history of head injuryhistory of heart attackhistory of strokehistory of high blood pressurehistory of diabeteshistory of cancerhistory of seizurenone of the above 14: These are common social problems that people have. Please check the problems that apply to you. not getting along with other peoplebeing criticized by othersnot fitting in with peersfeeling uncomfortable in social settingsacting rude or overbearingacting in an immature waybeing suspicious of othersbeing shynot having close friendsnone of the above 15: These are also some additional common social problems that people have. Please check the problems that apply to you. feeling lonelybeing unpopularbeing uncomfortable when talking to peoplefeeling inferiorfeeling like people are against mebeing embarassed by family backgroundbeing let down by friendsfeeling different from everyone elsenot having anyone to share interests withnone of the above 16: These are some other common problems that people have about their appearance. Please check the problems that apply to you. being clumsy and awkwardnot being clean and well-groomednot having suitable clothesbeing noticed for physical appearancehaving scarshaving facial blemishesnone of the above 17: These are common concerns problems that people have about their appearance. Please check the problems that apply to you. being overweightbeing too short or too tallhaving physical handicapbeing too thinlooking too oldhaving unattractive facenone of the above 18: These are common problems that people have about their career. Please check all that apply to you. not having a jobjob not paying enoughdislike type of jobjob being dirtydisliking fellow employeesbeing disliked by co-workersbeing afraid of failing on the jobbeing afraid of being fired or laid offbeing afraid of being injured on the jobnone of the above 19: These are some other common problems that people have about their career. Please check all that apply to you. friends or relatives criticizing joblack of supervision on the jobboss being critical or unfairhaving arguments on the jobworking too many hoursjob having no futurejob creating health problemsneeding more education to succeed in jobbeing bored on jobnone of the above 20: These are some common family problems that people have. Please check all that apply to you. children misbehavingdisagreeing on how to raise childrenchild or spouse having medical problemschild or spouse having emotional problemsspouse having problems with drugs or alcoholhaving problems with in-lawshaving problems with parentsbeing separated or divorced from spousehaving constant arguments with spousenone of the above 21: These are some other common family problems that people have. Please check all that apply to you. parents constantly arguingwanting to have childrennot wanting to have a child or more children.parents being too strictparents interfering with decisionsspouse having different interestsspouse having different backgroundparents being separated or divorcedspouse being unfaithfulnone of the above 22: These are some other common family problems that people have. Please check all that apply to you. not being understood by spousebeing unfaithful to spousehaving too much contact with relativesspouse working too many on jobarguing with spouse about moneyarguing with spouse over household choreshouse or apartment being too smallhouse or apartment needing repairshaving problem with landlordnone of the above 23: These are some other common family problems that people have. Please check all that apply to you. not getting along with neighborsnot having any privacy at homenot being able to afford living aloneliving under unsanitary or dirty conditionschildren leaving homeliving in dangerous neighborhoodnone of the above 24: These are common financial problems that people have. Please check the problems that apply to you. Budgeting moneynot making enough moneynot having a steady incomehaving to spend savingshaving unpaid billswasting moneynone of the above 25: These are some additional common financial problems that people have. Please check the problems that apply to you. depending upon others for financial supportlending money to friends or relativesnot being able to pay medical billsspouse being careless with moneynot hvaing enough money for educationdealing with bill collectorsnone of the above 26: These are common religious concerns that people have. Please check the problems that apply to you. feeling guilty about religionnot having any religious beliefsarguing about religionbeing confused about religious beliefsnot having good philosophy of lifefailing in religious beliefsarguing with spouse about religionnone of the above 27: These are some additional religious concerns that people have. Please check the problems that apply to you. not being able to get to churchfeeling abandoned by Godwork interfering with religious practicesbeing upset by religious beliefs of othersworry about being accepted by Godbeing rejected by churchfailing to support churchnone of the above 28: These are some common emotional concerns that people have. Please check the problems that apply to you. feeling anxious or uptight or being afraid of thingshaving the same thought over and over againbeing tired and having no energyfeeling depressed or sadhaving trouble concentratingnot remembering thingsgetting too emotionalfeeling guiltyworrying about diseases or illnessnone of the above 29: These are some additional emotional concerns that people have. Please check the problems that apply to you. being afriad of hurting selffeeling things are unrealcrying without good reasonworry about having a nervous breakdownnot being able to stop worrying; not being able to relaxbeing unhappy all the timenot having any enjoyment in lifebeing influeced by othersbehaving in strange waysnone of the above 30: These are common sexual concerns that people have. Please check the problems that apply to you. being uncomfortable with opposite sexbeing afraid of sexual diseasebeing gayworry about sexual performancenot knowing enough about sexnot having someone to talk to about sexbeing bi-sexualbeing involved in a current extramarital affairhaving had a previous extra-marital affairnone of the above 31: These are additional sexual concerns that people have. Please check the problems that apply to you. being sexually attracted to people of my own sexhaving or currently engaging in what I consider unusual sexual practicesnot being able to respond sexually to my partnermasturbating more frequently than I feel I shouldbeing ashamed of current sexual activitiesbeing ashamed of past sexual activitiesnone of the above 32: These are some additional sexual concerns that people have. Please check the problems that apply to you. having problems with sexual relationshiphaving unsatisfactory sexual relationshipthinking about sex too oftendisliking sexbeing trouble by sexual attitudes of othersbeing troubled by unusual sexual behaviorbeing sexually underdevelopednone of the above 33: These are some legal concerns that people have. Please check the problems that apply to you. needing legal advicebeing suednot having retirement fundsbeing someone's guardianbeing on parolebeing legally disowned by familynot receiving child support; not receiving child supporthaving legal problems with neighborsfacing criminal chargesnone of the above 34: These are some health concerns that people have. Please check the problems that apply to you. being physically hurtlosing temper and hurting someonehaving thoughts of suicidenot being able to relaxsmoking too many cigarettesusing drugs or alcoholnot getting enough exercisehaving poor sleeping habitseating too muchnone of the above 35: These are some additional health concerns that people have. Please check the problems that apply to you. having a physical disabilityhaving a chronic illnesshaving recurring health problemshaving many health problemsbeing unhappy with medical carewatching too much televisionnot having any hobbiesneeding a vacationhaving poor eating habitsnone of the above 36: These are some crises that happen in people's lives. Please check the problems that apply to you. friend or family member committing suicidefriend or family member having serious illnessfriend or family member getting a divorcefriend or family member dyingpet dyinglosing something valuablenone of the above 37: These are some additional crises that happen in people's lives. Please check the problems that apply to you. friend or family member attempting suicidefriend or family member losing jobfriend or family member being emotionally upsetbeing robbedchild running away from homelosing jobnone of the above 38: These are common disorders with which people are diagnosed. Please indicate any that apply to you: I have been told that I have bipolar disorder.I have been told that I have major depressive disorder.I have been told that I have generalized anxiety disorder.I have been told that I have posttraumatic stress disorder.I have been told that I have an addictive disorder.I have been told that I have a sexual disorder.I have been told that I have a personality disorder.I have been told that I have a conversion disorder.I have been told that I have schizophrenia or other psychotic disorder.none of the above 39: Please list any other problems that you are having and/or any other information you feel would assist me in helping you. More...
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