SELF-ASSESSMENT FOR ADULTS: HOW AM I DOING PSYCHOLOGICALLY?

Please answer the following questions on a scale of 1 to 5, with 1 being the least and 5 being the most.

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* 1. Please enter the following information:

Name *

Age

Email Address *

Phone Number *

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* 2. How did you learn of this assessment?

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* 3. I have severe or frequent sadness.

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* 4. I have severe or frequent anger or hositility.

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* 5. I have severe or frequent loneliness.

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* 6. I have severe or frequent fear or worry.

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* 7. I have severe or frequent resentment.

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* 8. I have severe or frequent guilt or regret.

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* 9. I can't get certain thoughts out of my mind.

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* 10. I can't stop myself from doing some actions repeatedly.

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* 11. I think about hurting or killing myself or someone else.

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* 12. I have a history of being abused by someone (emotionally, physically, and/or sexually).

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* 13. I am emotionally overwhelmed, or cry frequently.

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* 14. I am often misunderstood by others.

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* 15. I have too little energy.

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* 16. I have little pleasure in life.

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* 17. I have unusual eating habits.

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* 18. I don't sleep well.

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* 19. I have trouble waking up in the morning.

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* 20. I have nightmares or flashbacks.

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* 21. I have problems with attention or concentration.

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* 22. I have problems making or keeping friends or a partner.

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* 23. I am estranged from relatives, or have lots of family conflict.

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* 24. I have relationship or marriage problems.

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* 25. I have sexual difficulties.

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* 26. I have problems with job or school.

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* 27. I sometimes drink too much.

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* 28. I use illegal drugs, or take prescriptions medicines without doctors' orders.

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* 29. I am feeling the strain of being a caregiver to an ill or impaired friend or relative.

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* 30. I find it hard to speak my mind to people.

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* 31. I sometimes hear or see things that people around me cannot see or hear.

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* 32. I break the law more than most people do.

Thank you for taking this assessment. Dr. Paul will contact you to schedule a complementary appointment for visiting his office and reviewing your results together.