by THOMAS on Apr 3, 2012 • 2:32 am
Instructions: please enter the appropriate response to the statements below
Date:__________________
0 = Never/ Rarely
1 = Occasionally/ slightly
2 = Moderate in intensity or Frequency
3 = Intense / Severe or Frequent
I have not felt well since _______________ when ___________________________
(Date) (Describe event, if any)
Predisposing Factors
Past Now
1. _____ _____ I have experienced long periods of stress that have affected my well being
2. _____ _____ I have had one or more severely stressful events that have affected my well Being.
3. _____ _____ I have driven myself to exhaustion.
4. _____ _____ I overwork with little play or relaxation for extended periods.
5. _____ _____ I have had extended, severe or recurring respiratory infections.
6. _____ _____ I have taken long term or intense steroid therapy (corticosteroids)
7. _____ _____ I tend to gain weight, especially around the middle.
8. _____ _____ I have a history of alcoholism &/ or drug abuse.
9. _____ _____ I have environmental sensitivities.
10. _____ ____ I have diabetes ( type II, adult onset, NIDDM).
11. _____ ____ I suffer from post traumatic stress disorder.
12. _____ ____ I suffer from anorexia. *