Physical:
Headaches
Indigestion
Stomach aches
Sweaty palms
Sleep difficulties
Dizziness
Fast, shallow breathing
Back pain
Tight neck, shoulders
Racing heart
Restlessness
Tiredness
Ringing in ears
Cold hands

Behavioral:
Excess smoking
Bossiness
Screaming shouting
Compulsive gum chewing
Critical of others and self
Pacing finger / foot tapping
Grinding of teeth
Overuse of alcohol
Compulsive eating
Inability to get things done
Unable to sit still
Biting fingernails

Emotional:
Crying
Nervousness, anxiety
Boredom-no meaning to things
Edginess-ready to explode
Feeling powerless to change things
Overwhelming sense of pressure
Anger
Loneliness
Unhappy for no reason
Easily upset

Cognitive:
Trouble thinking clearly
Forgetfulness
Lack of creativity
Memory loss
Inability to make decisions
Thoughts of running away
Constant worry
Loss of sense of humor
Excessive compulsive thoughts

Spiritual:
Apathy
Emptiness
Lack of purpose
Unworthiness
Shame
Hopelessness
Separateness
Unable to surrender/let go
Fearful
Powerlessness

Comments:

First Name: Last Name:

  Address1:

  Address2:

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  State:          Zip:

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  Home Phone: Work Phone:

Male   Female