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Name

Questions 002-009

I am a possessive and jealous person frequently

I am afraid of dying

I am becoming secretive and unwilling to socialise

I am crying frequently

I am currently dealing with bereavement

I am currently dealing with financial problems

I am currently dealing with illness, either mine or someone close

I am currently dealing with loss of a relationship

Questions 010-019

I am currently feeling like I may hit "burn out‟ in my life

I am experiencing constant feelings of tiredness and exhaustion for no apparent reason

I am experiencing feelings of guilt

I am experiencing feelings of hopelessness about my future

I am experiencing feelings of loss

I am experiencing frequent worry or anxiety

I am experiencing irritability or frequent agitation

I am experiencing loss of appetite or eating too much

I am experiencing loss of energy

I am experiencing loss of personal pride

Questions 020-029

I am experiencing loss of sexual desire

I am experiencing poor appetite

I am experiencing poor digestion or frequent IBS like symptoms

I am experiencing regular insomnia or sleep disturbance

I am experiencing unwanted thoughts about an event in my past

I am feeling afraid currently

I am finding it difficult to concentrate or focus for any length of time

I am finding it difficult to make decisions currently

I am frequently rude or sarcastic to others

I am gaining or losing weight without trying to

Questions 030-039

I am having difficulty maintaining my normal working practices

I am having difficulty sleeping or sleeping too much

I am not getting pleasure from my normal pleasurable activities

I am obsessed with exercise

I am often very opinionated and disagree with others regularly

I am or have been contemplating ending my life

I am secretive about food

I am withdrawing from my usual social and support networks

I become preoccupied with thoughts of food or cravings

I cry a lot currently

Questions 040-049

I cut my food into small pieces to look as though I have eaten some, and become obsessed with what other people are eating

I deny being underweight or having a problem with food

I dislike my appearance

I do not trust other people, even those close to me

I eat very little, if at all, or restrict types of food, such as any containing fat

I experience flashbacks about an event in my past

I experience frequent hand tremors or body twitching

I experience trouble with breathing and experience shortness of breath

I feel a sense of dread in everyday life

I feel guilty

Questions 050-059

I feel hopeless regarding my current and future

I feel less attractive or desirable than I used to

I feel nervous

I feel or think that my family and friends would be better off without me

I feel or think that my life is not worth living

I feel sad

I feel that as I have already experienced at least one panic attack that I will definitely have another one.

I feel that I am unable to function when I am alone and have an anxiety/panic attack.

I feel that I have low self-worth

I feel that I must be with my partner or friend to be safe from experiencing another anxiety/panic attack.

Questions 060-069

I feel that if I have another anxiety/panic attack that I will definitely lose control and everyone will look at me.

I feel that if I have another anxiety/panic attack that I will lose my sanity and be locked up.

I feel that if I have another anxiety/panic attack that people will laugh at me or lose respect for me or see me as weak and vulnerable.

I feel that if I have another anxiety/panic attack, I will die.

I feel that it is my fault that I feel like this

I feel that life and people treat me very unfairly

I find it difficult to relax

I find myself becoming obsessive with people or things

I find myself self-critical or self-judgemental currently

I find myself thinking or planning my suicide

Questions 070-079

I find myself unable to relax

I find that I can deal with large problems but find smaller ones much harder to sort out

I find that I get easily frustrated and annoyed

I find that I no longer have any motivation to do things

I focus upon my failures

I frequently become angry or annoyed for no apparent reason

I frequently experience 'road rage' or other forms of social rage

I frequently focus upon my weaknesses and imperfections

I frequently imagine the worst things happening to myself or family members

I frequently tell people what I think of them

Questions 080-089

I get frequent headaches

I get frequent indigestion or IBS like symptoms

I get irritable very easily

I go to bed at night and wish that I would not wake up again

I go to bed at night and wish that I would wake up successful, attractive and happy

I hate or dislike myself

I have a binge-purge cycle at least twice a week for three months or more

I have a body weight that is much less than expected for my age and height

I have a distorted body image

I have a fear or sense of losing control

Questions 090-099

I have an intense dread of gaining weight

I have been arrested, been held at a police station, or had any other legal problems because of my drinking or substance use

I have been verbally abusive to others

I have continued to drink or use even though I knew it was causing issues with my family or friends

I have continued to drink or use even though I knew it was making me feel depressed or anxious, causing or making a health problem worse, or causing a blackout

I have difficulty in concentrating or focusing on easy tasks or making decisions

I have experienced a traumatic event recently

I have found that I have to drink or use much more than I once did to get the effect I want, or that my usual usage or intake has much less effect on I than it once did

I have frequent weight changes

I have given up activities that I enjoyed in order to accommodate my eating patterns

Questions 100-109

I have given up activities that I enjoyed in order to make more time for my drinking or substance use

I have got into physical fights or violent episodes while drinking or using, or right after drinking or using

I have got into situations while drinking or using, or after drinking or using, that increased my chances of getting hurt—like swimming, using machinery, walking in a dangerous area, or near heavy traffic

I have had a period when I spent a lot of time drinking or using, being sick, or getting over the negative after-effects of drinking or using

I have had a period when my usage—or being sick from my usage— has interfered with taking care of my home or family, or caused job or educational issues

I have had an anxiety/panic attack.

I have had anxiety/panic attacks when I have been away from home or a safe environment.

I have had times when I ended up drinking or using more than I meant to, or kept on drinking or using for longer than I intended

I have lost control and have become physically aggressive

I have lost interest in my life/family/friends

Questions 110-119

I have lost pleasure in my usual activities or hobbies

I have nightmares about an event in my past

I have on more than one occasion wanted to or tried to stop my eating constraints

I have on more than one occasion wanted to or tried to stop or cut down on my drinking or using but found I were unable

I have recently had a child or a family member moved in with me

I have recently lost my job, house or gone bankrupt

I have taken a drink or used any drug or medicine (other than over-the-counter pain relievers) to avoid having bad after-effects of usage, or to get over an after-effect of alcohol or substance use

I have very high personal standards regarding my behaviour and that of my friends

I have, more than once, driven a vehicle while I were drinking or using, or after having had too much to drink or after taking too much

I make myself vomit after meals or use laxatives or pills that remove water from my body

Questions 120-129

I not eat with others or disappear to the toilet after meals to vomit the food I have eaten

I obsessively weigh measure and examine my body

I often feel like I will explode because I get so angry

I often feel nervous for no apparent reason

I often feel very isolated or alone

I often react very quickly to others or circumstances

I often think that people are talking about me behind my back

I secretly hoard away food

I self-harm

I suffer from frequent indigestion

Questions 130-139

I tend to act first and then think about the consequences of my actions

I tend to be very intimidating or threatening to other people

I think that I are currently stressed

I use appetite suppressants such as diet pills

I wear baggy clothes to disguise my weight loss

I worry or feel anxious about my physical or emotional health

I would say I am a perfectionist

I would say that I am successful in life generally

I would say that I become very focused on time or lack of it

I would say that I have a current heavy workload

Questions 140-149

I would say that my life is very dramatic currently

My eating pattern caused issues with my family or friends

My heart feel like it is racing or pounding very fast without engaging in aerobic exercise

My home life causes me stress

My job makes me stressed

Sometimes I get so angry, I could kill

When I become angry, I destroy things.

When I feel pressured, I always react with anger or rage

When I have an anxiety/panic attack I cry or scream.

When the effects of alcohol or substances are wearing off have I experienced physical symptoms such as shaking, feeling nervous, nauseous, restless, sweating or rapid heartbeat I have sensed things that aren’t really there, felt bugs crawling on my skin, or had seizures

Scores

Alcohol/Substance Use

Anger Management

Anxiety

Panic

Depression

Eating

PTSD

Self Esteem

Stress

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