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Could Subconscious Stress Be at the Root of Your Chronic Symptoms?
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How did you hear about us?
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Please indicate any difficulties you faced as a child (to age 18). Select all that apply.
Born prematurely, had birth trauma or congenital defect requiring intensive medical care.
Experienced hunger or other deprivations.
Parents or guardians rejected your sad, angry or hurt feelings or demanded cheerfulness at all times.
Had a parent who was angry, controlling, perfectionistic, or demanding.
Suffered severe physical or emotional punishments.
Experienced a childcare situation where you felt unwanted or uncared for.
Shamed or humiliated in the home, threatened, or bullied.
Family moved from one community to another multiple times.
Parents preoccupied with ongoing community violence or world events.
Family immigrated from another country.
Experienced discrimination.
Intimidated or physically threatened by a parent or other adult at home.
Felt unloved, unwanted, or neglected by parents or guardians.
Parents or adults in the home were alcoholic or addicted.
One or more parents were emotionally-needy, self-absorbed, workaholic or otherwise unavailable emotionally.
Felt emotionally distant from parents: "They didn't know me."
Difficult home life required you to take care of siblings, parents or to have responsibilities beyond your years.
Witnessed physical or emotional abuse of a parent or sibling.
Experienced physical, emotional or sexual abuse, including rape.
Separated from parents during childhood.
Lost a parent to death, jail time, divorce, or any other reason.
Had a parent who was depressed, suicidal or mentally ill.
Serious illness or medical trauma in a close family member.
Over-identified with a parent or sibling --took on their pain.
Other
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Please indicate all personality traits that you identify with -- select all that apply.
Perfectionist
People-pleaser
Caretaker/nuturer
Peacemaker or Conflict-Avoider
Helper/Fixer/Savior
"Can't say No."
Tendency toward depression
Even keeled; doesn't feel high or low emotions.
High achiever, driven to succeed
Overly responsible; often carries the load for the group.
"People say I'm too serious."
Always doing: can't relax.
Chameleon: "I become whoever the person I'm with wants me to be."
Deflector: Laughs or jokes to deflect intense or negative emotions.
"Too nice" -- never expresses anger or resentment.
Low self-esteem. Sensitive to criticism.
Overly self-reliant; never wants to be a burden on others.
Too good. Conscientious to a fault.
Too sensitive - feels their own and other people's emotions keenly.
Worrier - tendency toward anxiety, worry, or catastrophizing.
Obsessive negative thoughts, compulsions.
High-strung or "hyper"
Other
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Please indicate all sources of life stress, either concurrent with symptoms or leading up to the onset of symptoms.
Death in the family.
Serious or fatal condition or diagnosis in a close family member.
Serious or fatal condition or diagnosis (self or child).
Caretaking role for family member.
Loss of job, livelihood. Business downturn or sale of business (for a business owner.)
Divorce or separation. Relationship stress.
Financial loss, or instability.
Lost home or forced to move from home.
Concerns about aging or retirement.
Physical degeneration due to aging or disease process leading to loss of regular activities.
Physical injury or trauma, including medical/dental procedures.
Physical, emotional or sexual assault or abuse.
Toxic environment at home or at work (chemical/biological toxins, or emotional toxicity.)
Loss of sense of purpose.
Feeling of betrayal from someone close to you.
Intense or prolonged deadline pressure at work or school.
Involved in a legal proceeding.
Other
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Please indicate all mental or physical health issues that you have experienced. Select all that apply.
Chronic back pain, joint pain, shoulder pain, tennis elbow, foot pain, plantar fasciitis, muscle tension, muscle spasms, tendonitis, carpal tunnel, sciatica or bursitis
Hormonal imbalances, including hyper or hypothyroiism, adrenal fatigue, dysmenorrhea, skipped periods, infertility.
Irritable bowel syndrome, nervous stomach, stomach pain, reflux, nausea, leaky gut or chronic diarrhea/constipation
Migraines, cluster headaches, headaches, TMJ, bruxism, tooth, jaw, or mouth pain
Recurrent infections: sinus, urinary, bladder or other
Chronic viral or bacterial infections (Epstein Barr, Lyme, etc.) or MCAS
Any autoimmune condition including Hashimoto's thyroiditis, asthma, rheumatoid arthritis, multiple sclerosis, lupus, inflammatory bowel disease, psoriasis.
Chronic fatigue syndrome, chronic pain syndromes, or fibromyalgia
Allergies or sensitivities to foods, chemicals, medications, environmental irritants (mold, dust, pollen, etc.), or heights, heat, sounds, lights, weather, exertion, etc.
Acne, eczema, hives, rashes, skin eruptions, or flushing
Depression, anxiety, or panic attacks
Frequent urination (not related to pregnancy or diabetes), high blood pressure, dizziness/vertigo, POTS, Raynaud's or tinnitus
Eating disorders, restricted eating, binge eating, or obsessive behaviors.
Insomnia, sleep apnea, interrupted sleep, bedwetting, or recurring nightmares
Addictions and addictive behaviors.
Stuttering, stammering or tics.
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