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Health Questionnaire (9 questions)
Over the
last 2 weeks
, how often have you been bothered by any of the following problems?
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Little interest or pleasure in doing things
*
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
*
Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much
*
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
*
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
*
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself -- or that you are a failure or have let yourself or your family down
*
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite -- being so fidgety or restless that you have been moving around a lot more than usual
*
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
*
Not at all
Several days
More than half the days
Nearly every day
If you checked off any problems in the above questions, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Submit
Home
About Us
Nancy Bunt
Hours
Directions
Rates
Health Insurance Information
Services
Reiki Treatment
Reiki Training
>
Reiki For The Self
Reiki For Others
Reiki Second Degree
Reiki Master Teacher
Reiki Consulting
iRest® Self-Inquiry Meditation
SoulCollage®
TRE®
Live Workshops
Online Courses
Free Meditation Library
Online Booking
Store
Blog
Contact