Wait..Don't Go Before You Get YOUR FREE Mental Health Assessment !!!

FOR NEW YORK CITY AND NEW YORK STATE RESIDENTS

TAKE OUR PSYCHOLOGISTS FREE LIFE AND LIFE STYLE TEST..THE RESULTS MAY SURPRISE YOU!

All Information is kept Confidential

Simply print out this form and mail it to the address listed below. You can also fax it to us at 845 292 5101.

Once we receive your questionnaire, we will contact you to discuss the results.

FIRST NAME: ____ HOME PHONE:_ _____________________ CITY: _ STATE: _ ZIP: _ COMMENTS: _
_______________________________

PLEASE ANSWER EACH QUESTION AS FOLLOWS:
1. NEVER
2. RARELY
3. SOMETIMES
4. USUALLY
5. ALWAYS
6. NOT APPLICABLE

1. My hands get cold and clammy ___
2. There is a band of tension around my head ___
3. My neck is stiff and hurts when I move my head ___
4. There is a lot of pain in the lower part of my back ___
5. I feel as if I am not getting enough air ___
6. My chest muscles feel tight ___
7. I get light-headed and feel dizzy ___
8. I clench my jaws and/or grind my teeth ___
9. I have cramping and pain in my stomach ___
10. It often feels as if my blood pressure was up ___
11. I get angry over nothing ___
12. I have trouble remembering names and appointments ___
13. I feel depressed often ___
14. I don't remember what I read ___
15. I tell myself what I should do and then don't do it ___
16. I remember errors and ignore successes ___
17. I feel as if I can't change the bad things in my life ___
18. I feel tired and fatigued ___
19. I feel responsible for the bad things that happen to others ___
20. I get irritated when my plans don't work out ___
21. I yell at others for no good reason ___
22. Meeting strangers gets me upset ___
23. I have trouble telling others what I want ___
24. I get upset when others praise me ___
25. I feel alienated from my family ___
26. My friends seem more successful than I am ___
27. I never know what to do with aggressive people ___
28. I have trouble giving other people negative feedback ___
29. I have difficulty expressing differences of opinion to others ___
30. I am impatient with other people ___
31. I resent my parents ___
32. I drink too much ___
33. I overeat too much ___
34. I smoke but want to stop ___
35. I feel tense ___
36. I feel nervous ___
37. I have spells of terror or panic ___
38. I get upset easily or feel panicky unexpectedly ___
39. I feel powerless to do anything about my life ___
40. I lack self confidence ___
41. I enjoy being with other people ___
42. I feel terribly lonely ___
43. I feel overwhelmed ___
44. I feel many people don't like me ___
45. It is very hard for me to relax ___
46. I feel I have marital problems ___
47. I feel tense and angry with those around me ___
48. I feel I must race from one task to the next ___
49. I like the way I look ___
50. I really do not care to be around my family ___
51. I feel that our relationship is breaking up ___
52. My partner really doesn't understand me ___
53. I feel that people would not like me if they really knew me well ___
54. I feel I need more love ___
55. I feel neglected ___
56. I have a low opinion of myself ___
57. I have problems at work ___
58. When I drink I get intoxicated ___
59. I'm told I drink to much ___
60. When I'm upset, I like to have a drink ___
61. Handling cigarettes is enjoyable ___
62. Smoking a cigarette calms me ___
63. When I'm upset I'll light up ___
64. I over eat when I'm sad ___
65. I over eat when I'm nervous ___
66. I over eat when I'm frustrated ___
67. When others eat, I join in ___
68. Talking about food makes me hungry ___
69. I stuff myself in private ___
70. I'd like to be loved for my appearance ___
71. I feel people are happiest as children ___
72. I like being an adult ___
73. I'm told I'm a perfectionist ___
74. I recently had a very bad experience ___
75. My friends are not a good influence ___
76. I am jealous and envious ___

YOU MAY RETURN YOUR STRESS SURVEY QUESTIONNAIRE BY mailing it to:

SOLUTIONS FOR HEALTH
c/o P.O. BOX 180253
BROOKLYN, N.Y. 11218
or faxing it to 845 292 5101t
For additional information about our psychologists and our services, call us at 1-800-576-PHDS.
Always remember your privacy is important to us! Thank you for stopping by!