QUESTIONS BY CATEGORY:
Health and Well-Being

Current Health Status

Have you ever participated in professional counseling or psychotherapy sometime in your life?

Which of the following best describes how often you participated in professional counseling or psychotherapy in your life?

Thinking about your overall health status, are you currently experiencing any serious problems with your health?

Would you say you experience serious health problems: (categories)

In the past 2 years has there been a serious physical or mental health crisis with any member of your immediate family?

Thinking about your overall emotional life, are you currently experiencing any serious problems with your emotional relations?

Would you say you experience serious emotional problems: (categories)

Thinking about your general job history, are you currently experiencing any serious problems with your worklife?

At any point in the past four weeks, have you felt so sad and unhappy that nothing could cheer you up?

Would you say you have this experience: (frequency)

At any point in the past four weeks, have you felt so anxious and agitated that nothing could calm you down?

Would you say you have this experience: (frequency)

Have you ever used tobacco products?

Have you ever used alcohol?

Would you say you drink alcohol: (frequency)

Have you ever used marijuana?

Would you say you use marijuana: (frequency)

Have you ever used LSD, mescaline or psilocybin?

Have you ever used cocaine, methamphetamines, or ecstasy?

Trauma and Negative Life Experiences

As a child or teenager, were you ever assaulted by a parent, for example being hit or kicked to the point of physical injury such as bruising or cuts?

Would you say you had this experience: (frequency)

Have you ever experienced a physical assault from someone who was not a member of your family?

At any time in your life, have you ever lived in a place that was a war zone or armed conflict, or have you been at some point a combatant?

Have you ever been in a major accident like a car crash or plane crash?

Alternative Health Care Practices

Do you currently use vitamins and nutritional supplements as a part of your personal health strategy?

Have you used chiropractic care, massage, Rolfing, or other visceral or skeletal manipulation in the last two years?

Have you used naturopathy, homeopathy, or herbal medicine as an alternative healing method in the last two years?

Have you used acupuncture as an alternative healing method in the past two years?

Have you ever used energy or faith healing as an alternative healing method in the past two years?

Which of the following best describes how frequently you used energy or faith healing in the past two years?

x

back to top