Name
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First Name
Last Name
How often do you feel physically sick, sluggish, and tired?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you feel emotionally drained, empty, numb, and tired?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you feel resentful, victimized, traumatized, or abandoned?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you feel angry, vengeful, bitter, jealous, and spiteful?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you feel like you self-sabotage, give up, miss opportunities, push people away?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you feel like a quitter, failure, or undeserving of accomplishing your goals?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you binge-watch television?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you watch or read the news?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you scroll uncontrollably on social media?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you get drunk?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you drink soda, sports drinks, or energy drinks?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you eat fast food, junk food, foods high in sugar, or candy?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
How often do you smoke cigarettes?
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Not Applicable
Not Much
Maybe Sometimes
Often
Pretty Frequently
Too Much
Please use this text box to elaborate on any of your answers, describe other feelings, habits, activities you do/feel too much, or express any feeling that came up as a result of completing this form.
