My spouse/significant other are having difficulties
Communicating
Resolving conflict
Getting along
With intimacy
Something else
None/not applicable
I am sad often
Yes
No
I am often very anxious
Yes
No
I am socially awkward
Yes
No
I am conniving and manipulative
Yes
No
Things aren't fun or rewarding anymore
Yes
No
I have no energy
Yes
No
I can go for days without the need for sleep
Yes
No
I hear voices of people that are not there
Yes
No
I have been feeling overwhelmed
Yes
No
I eat the recommended daily amount of food/nutrition for my height/weight/frame/age/medical disposition
Yes
No
I have diabetes
Yes
No
I have chronic pain
Yes
No
I want to lose weight
Yes
No
I am overly concerned by what people say about me
Yes
No
I smash or break things when I am angry
Yes
No
I have difficulty controlling my impulses
Yes
No
I slam doors when I'm angry
Yes
No
People don't seem to listen when I talk to them
Yes
No
I have nightmares often
Yes
No
I drink more than I should
Yes
No
I'm a pothead
Yes
No
I'm trying to quit smoking
Yes
No
I use meth or other stuff that isn't good for me
Yes
No
I am in AA, NA, Or have a spouse or close family member that is
Yes
No
My kids are driving me up the wall
Yes
No
I have no friends
Yes
No
I have trouble coping
Yes
No
I recently lost someone close to me
Yes
No
I have been traumatized (physically, emotionally, or otherwise)
Yes
No
I wash my hands constantly (no, I'm not a surgeon)
Yes
No
I have peculiar rituals that no one else seems to do
Yes
No
I have severe, even crippling, irrational fears
Yes
No
I am highly sensitive to my fears of being rejected
Yes
No
People say I act immaturely for my age
Yes
No
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