Name
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Phone Number
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Email Address
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Address
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City, State, Zip
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Do you have difficulty sleeping or staying asleep?
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Do you have marital, family or financial worries?
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Do you often feel confused and find it difficult to make decisions?
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Do you find it difficult to remember simple daily things?
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Do you have feelings of anxiousness or depression?
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Do you tend to magnify insignificant events?
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Are you highly emotional and often fearful of many things?
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Do you often crave sweets and find yourself eating when nervous?
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Do you find it difficult to function when under even slight pressure?
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Have you had several high stress events occur within the last year?
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