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: I don’t have any difficulty eating slowly in the proper manner.Although I seem to “gobble down” foods, I don’t end up feeling stuffed because of eating too much.At times, I tend to eat quickly and then, I feel uncomfortably full afterwards.I have the habit of bolting down my food, without really chewing it. When this happens I usually feel uncomfortably stuffed because I’ve eaten too much. 40: I don’t feel self-conscious about my weight or body size when I’m with others.I feel concerned about how I look to others, but it normally does not make me feel disappointed with myself.I do get self-conscious about my appearance and weight which makes me feel disappointed in myself.I feel very self-conscious about my weight and frequently, I feel intense shame and disgust for myself. I try to avoid social contacts because of my self-consciousness. 41: I feel capable to control my eating urges when I want to.I feel like I have failed to control my eating more than the average person.I feel utterly helpless when it comes to feeling in control of my eating urges.Because I feel so helpless about controlling my eating I have become very desperate about trying to get in control. 42: I don’t have the habit of eating when I’m bored.I sometimes eat when I’m bored, but often I’m able to “get busy” and get my mind off food.I have a regular habit of eating when I’m bored, but occasionally, I can use some other activity to get my mind off eating.I have a strong habit of eating when I’m bored. Nothing seems to help me break the habit. 43: I’m usually physically hungry when I eat something.Occasionally, I eat something on impulse even though I really am not hungry.I have the regular habit of eating foods, that I might not really enjoy, to satisfy a hungry feeling even though physically, I don’t need the food.Even though I’m not physically hungry, 1 get a hungry feeling in my mouth that only seems to be satisfied when I eat a food, like a sandwich, that fills my mouth. Sometimes, when I eat the food to satisfy my mouth hunger, I then spit the food out so I won’t gain weight. 44: I don’t feel any guilt or self-hate after I overeat.After I overeat, occasionally I feel guilt or self-hate.Almost all the time I experience strong guilt or self-hate after I overeat. 45: I don’t lose total control of my eating when dieting even after periods when I overeat.Sometimes when I eat a “forbidden food” on a diet, I feel like I “blew it” and eat even more.Frequently, I have the habit of saying to myself, “I’ve blown it now, why not go all the way” when I overeat on a diet. When that happens I eat even more.I have a regular habit of starting strict diets for myself, but I break the diets by going on an eating binge. My life seems to be either a “feast” or “famine.” 46: I rarely eat so much food that I feel uncomfortably stuffed afterwards.Usually about once a month, I eat such a quantity of food, I end up feeling very stuffed.I have regular periods during the month when I eat large amounts of food, either at mealtime or at snacks.I eat so much food that I regularly feel quite uncomfortable after eating and sometimes a bit nauseous. 47: My level of calorie intake does not go up very high or go down very low on a regular basis.Sometimes after I overeat, I will try to reduce my caloric intake to almost nothing to compensate for the excess calories I’ve eaten.I have a regular habit of overeating during the night. It seems that my routine is not to be hungry in the morning but overeat in the evening.In my adult years, I have had week-long periods where I practically starve myself. This follows periods when I overeat. It seems I live a life of either “feast or famine.” 48: I usually am able to stop eating when I want to. I know when “enough is enough.”Every so often, I experience a compulsion to eat which I can’t seem to control.Frequently, I experience strong urges to eat which I seem unable to control, but at other times I can control my eating urges.I feel incapable of controlling urges to eat. I have a fear of not being able to stop eating voluntarily. 49: I don’t have any problem stopping eating when I feel full.I usually can stop eating when I feel full but occasionally overeat leaving me feeling uncomfortably stuffed.I have a problem stopping eating once I start and usually I feel uncomfortably stuffed after I eat a meal.Because I have a problem not being able to stop eating when I want, I sometimes have to induce vomiting to relieve my stuffed feeling. 50: I seem to eat just as much when I’m with others (family, social gatherings) as when I’m by myself.Sometimes, when I’m with other persons, I don’t eat as much as I want to eat because I’m self-conscious about my eating.Frequently, I eat only a small amount of food when others are present, because I’m very embarrassed about my eating.I feel so ashamed about overeating that I pick times to overeat when I know no one will see me. I feel like a “closet eater.” 51: I eat three meals a day with only an occasional between meal snack.I eat 3 meals a day, but I also normally snack between meals.When I am snacking heavily, I get in the habit of skipping regular meals.There are regular periods when I seem to be continually eating, with no planned meals. 52: I don’t think much about trying to control unwanted eating urges.At least some of the time, I feel my thoughts are pre-occupied with trying to control my eating urges.I feel that frequently I spend much time thinking about how much I ate or about trying not to eat anymore.It seems to me that most of my waking hours are pre-occupied by thoughts about eating or not eating. I feel like I’m constantly struggling not to eat. 53: I don’t think about food a great deal.I have strong cravings for food but they last only for brief periods of time.I have days when I can’t seem to think about anything else but food.Most of my days seem to be pre-occupied with thoughts about food. I feel like I live to eat. 54: I usually know whether or not I’m physically hungry. I take the right portion of food to satisfy me.Occasionally, I feel uncertain about knowing whether or not I’m physically hungry. At these times it’s hard to know how much food I should take to satisfy me.Even though I might know how many calories I should eat, I don’t have any idea what is a “normal” amount of food for me. 55: Please list any other problems that you are having and/or any other information you feel would assist me in helping you. More...
Loading ...
