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Home
About Us
Events
Offerings
Causes
Volunteer
Name
*
Date
How often have you experienced each of the following in the last month?
1. Headaches
*
0 Never
1 Rarely
2 Sometimes
3 Often
2. Insomnia
*
0 Never
1 Rarely
2 Sometimes
3 Often
3. Weight Loss (without dieting)
*
0 Never
1 Rarely
2 Sometimes
3 Often
4. Stomach Problems
*
0 Never
1 Rarely
2 Sometimes
3 Often
5. Sexual Problems
*
0 Never
1 Rarely
2 Sometimes
3 Often
6. Feeling isolated from others
*
0 Never
1 Rarely
2 Sometimes
3 Often
7. Flashbacks (suddent, vivid, distracting memories)
*
0 Never
1 Rarely
2 Sometimes
3 Often
8. Restless Sleep
*
0 Never
1 Rarely
2 Sometimes
3 Often
9. Low sex drive
*
0 Never
1 Rarely
2 Sometimes
3 Often
10. Anxiety Attacks
*
0 Never
1 Rarely
2 Sometimes
3 Often
11. Sexual overactivity
*
0 Never
1 Rarely
2 Sometimes
3 Often
12. Loneliness
*
0 Never
1 Rarely
2 Sometimes
3 Often
13. Nightmares
*
0 Never
1 Rarely
2 Sometimes
3 Often
14. Spacing Out (going away in your mind)
*
0 Never
1 Rarely
2 Sometimes
3 Often
15. Sadness
*
0 Never
1 Rarely
2 Sometimes
3 Often
16. Dizziness
*
0 Never
1 Rarely
2 Sometimes
3 Often
17. Not feeling satified with your sex life
*
0 Never
1 Rarely
2 Sometimes
3 Often
18. Trouble controlling your temper
*
0 Never
1 Rarely
2 Sometimes
3 Often
19. Waking up early in the morning
*
0 Never
1 Rarely
2 Sometimes
3 Often
20. Uncontrollable crying
*
0 Never
1 Rarely
2 Sometimes
3 Often
21. Fear of men
*
0 Never
1 Rarely
2 Sometimes
3 Often
22. Not feeling rested in the morning
*
0 Never
1 Rarely
2 Sometimes
3 Often
23. Having sex you didn't enjoy
*
0 Never
1 Rarely
2 Sometimes
3 Often
24. Trouble getting along with others
*
0 Never
1 Rarely
2 Sometimes
3 Often
25. Memory Problems
*
0 Never
1 Rarely
2 Sometimes
3 Often
26. Desire to physically hurt yourself
*
0 Never
1 Rarely
2 Sometimes
3 Often
27. Fear of women
*
0 Never
1 Rarely
2 Sometimes
3 Often
28. Waking up in the middle of the night
*
0 Never
1 Rarely
2 Sometimes
3 Often
29. Bad thoughts or feelings during sex
*
0 Never
1 Rarely
2 Sometimes
3 Often
30. Passing out
*
0 Never
1 Rarely
2 Sometimes
3 Often
31. Feeling that things are "unsure"
*
0 Never
1 Rarely
2 Sometimes
3 Often
32. Unnecessary or over-frequent washing
*
0 Never
1 Rarely
2 Sometimes
3 Often
33. Feeling of inferiority
*
0 Never
1 Rarely
2 Sometimes
3 Often
34. Feeling tense all the time
*
0 Never
1 Rarely
2 Sometimes
3 Often
35. Being confused about your sexual feelings
*
0 Never
1 Rarely
2 Sometimes
3 Often
36. Desire to hurt others
*
0 Never
1 Rarely
2 Sometimes
3 Often
37. Feeling of guilt
*
0 Never
1 Rarely
2 Sometimes
3 Often
38. Feeling that you are not always in your body
*
0 Never
1 Rarely
2 Sometimes
3 Often
39. Having trouble breathing
*
0 Never
1 Rarely
2 Sometimes
3 Often
40. Sexual feeling when you shouldn't have them
*
0 Never
1 Rarely
2 Sometimes
3 Often
Anything else you would like to share?
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