SELF EVALUATION

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Behaviors experienced

Have any family members (spouse, parents, grandparents, siblings, aunts, uncles, cousins, and/or child(ren) experienced any of the following behaviors)?

Depression

Depression Person(s)

Bi-polar

Bi-polar Person(s)

Anxiety

Anxiety Person(s)

Panic Attacks

Panic Attacks Person(s)

Schizophrenia

Schizophrenia Person(s)

Suicide Ideation/Attempts

Suicide Ideation/Attempts Person(s)

Homicidal Behavior

Homicidal Behavior Person(s)

Alcoholism

Alcoholism Person(s)

Drug Use

Drug Use Person(s)

Divorce/Infidelity

Divorce/Infidelity Person(s)

Domestic Violence

Domestic Violence Person(s)

Sexual Abuse/Incest

Sexual Abuse/Incest Person(s)

Child Abuse/Neglect

Child Abuse/Neglect Person(s)

Anorexia (self-starvation)

Anorexia (self-starvation) Person(s)

Bulimia (bingeing/purging)

Bulimia (bingeing/purging) Person(s)

ADD/ADHD

ADD/ADHD Person(s)

Learning Disabilities

Learning Disabilities Person(s)

Dementia/Alzheimer’s

Dementia/Alzheimer’s Person(s)

Internet Compulsivity

Internet Compulsivity Person(s)

Compulsive Gambling

Compulsive Gambling Person(s)

Financial Problems

Financial Problems Person(s)

EVALUATION FOR DEPRESSION

Within the last two (2) weeks have you experienced any of the following? (Please check all that apply):

Sadness/tearful
Significant Weight loss (<5%)
Crying Spells
Eating more than usual
Feelings of worthlessness/self-hate
Significant weight loss
Poor concentration
Eating less than usual
Difficulty making decisions
Postpartum symptoms
Restlessness
Thoughts of harming yourself
Fatigue/low energy
Thoughts of harming others
Poor sleep/insomnia
Cutting self to alleviate emotional pain
Significant weight gain (>5%)
Current or past suicide attempts
Eating more than usual
Current suicide plan

EVALUATION FOR MANIC EPISODES

During your lifetime have you ever experienced any of the symptoms listed below for at least a week or more? (Please check all that apply)

A long period of feeling “high” or an overly happy or outgoing mood
Extremely irritable mood, agitation, feeling “jumpy” or “wired”
Talking faster than usual; jumping from one idea to another; having racing thoughts
Being easily distracted
Sleeping very little
Having an unrealistic belief in one’s abilities
Behaving impulsively; engaging in high-risk behaviors ie spending sprees, gambling, sex, etc.

SLEEP HABITS

Have you experienced any of the symptoms listed below within the last two (2) weeks? (Please check all that apply

Difficulty falling asleep
Typical time asleep
Difficulty sustaining sleep
Typical time awake
Early morning awakening
Recent changes in sleep
Excessive sleep
Snoring/ C-Pap machine
Decreased need for sleep
Feeling sleep deprived during the day
Daytime napping
Nightmares

EATING HABITS

Have you experienced any of the symptoms listed below? (Please check all that apply)

Negative body image
Excessive eating
Anorexia (self-starvation)
Significant appetite decrease (>5%)
Bulimia (bingeing/purging)
Significant appetite increase (>5%)
Use of laxatives, diet pills, diuretics
Feelings of loss of control when eating

ANXIETY

Have you experienced any of the symptoms listed below within the last SIX (6) months more days than not? (please check all that apply)

Constant worrying/obsessing about concerns
Irritability
Restlessness and feeling “keyed up” or on edge
Muscle tension or muscle aches
Trembling; feeling twitchy/easily startled
Fatigue
Difficulty concentrating or mind going blank
Trouble sleeping

Check all the symptoms that develop abruptly and peak with 10 minutes? (Please check all that apply)

Sweating, nausea or diarrhea
Chills or hot flashes
Shortness of breath
Numbness or tingling sensation
Rapid heartbeat
Fear of losing control or going crazy
Chest pain or discomfort
Feeling dizzy, lightheaded or faint

AGORAPHOBIA

Have you experienced any of the symptoms listed below (Please check all that apply)

Fear of leaving home
Fear of traveling in a car
Fear of being in a crowd
Fear of standing in a line
Fear of elevators

OBSESSIVE COMPULSIVE BEHAVIOR (OCD)

THOUGHTS

Fear of being contaminated by germs or dirt or contaminating others
Fear of causing harm to yourself or others
Intrusive sexually explicit or violent thoughts or images
Excessive focus on religious or moral ideas
Fear of losing or not having things you might need
Order and symmetry: the idea that everything must line up “just right”
Superstitious; excessive attention to something considered lucky or unlucky

BEHAVIORS

Superstitious; excessive attention to something considered lucky or unlucky
Excessive double-checking of things, such as locks, appliances and switches
Repeatedly checking in on loved ones to make sure they’re safe
Counting, tapping, repeating certain words, or doing other senseless things to reduce anxiety
Spending a lot of time washing or cleaning
Ordering, evening out or arranging things “just so”
Praying excessively or engaging in rituals triggered by religious fear
Accumulating “junk” old papers, magazines, empty cartons, other unneeded items

POST TRAUMATIC STRESS BEHAVIOR (PTSD)

Have you experienced any of the symptoms listed below? (Please check all that apply)

Reliving a traumatic event that disturbs day to day activity (battlefield experience; car accident; physical/sexual abuse
Flashback episodes where the event seems to be happening again and again
Repeated upsetting memories of the event
Repeated nightmares of the event
Strong uncomfortable reactions to situations that remind you of the event
Avoiding people, places or thoughts that remind you of the event

ATTENTION AND CONCENTRATION

Have you experienced any of the symptoms listed below for at least six (6) months? (Please check all that apply)

Poor listener
Frequently forgetful
Difficulty sustaining attention
Frequently lose or misplace things
Easily distracted
Difficulty with planning and organization
Avoid tasks requiring concentration
Difficulty following through on assignment
Frequently make careless mistakes
Fail to finish assignments or tasks

SEXUAL HISTORY

Please check all that apply:

Satisfied with your sexual relationship
Male erectile dysfunction (ED)
Dissatisfied with sexual relationship
Orgasmic difficulties
Preoccupied with sexual fantasies
Genital pain associated with intercourse
Internet pornography
High libido
Compulsive masturbation
Low libido
Premature ejaculation
Past sexual abuse

ANGER MANAGEMENT

Please check all that apply

Suppress your anger due to fear of rejection and/or confrontation
Provoke others to get angry
Explode with anger rather quickly
Get angry when feeling ashamed, guilty, jealous and/or vulnerable
Verbal abuse towards spouse/family/friends when angry
Physical abuse towards spouse/family/friends when angry
Physically hurt yourself when angry

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