Emotional Symptom Survey Form

Emotional Symptom Survey Form
Name

First Name Last Name
Date

Month Day Year
Date Date Picker Icon
Instructions: Fill in only what applies to you.

Score: (1-5) Leave BLANK if they don't apply to you.
1=Mild / 5=Severe

Group 1: Pain

	1	2	3	4	5
Headaches
Migraines
Neck
Back
Shoulder
Elbow
Wrist
Hip
Knee
Ankle
Stomach
Other

Group 2: General Health

	1	2	3	4	5
Weight
Digestion
Allergies
Sinus
Skin

Group 3: Stress

	1	2	3	4	5
Past Work
Present Work
Past Home
Present Home
Significant Emotional Trauma

"Quality of" 1=Excellent / 5=Poor

Group 4: Relationships

	1	2	3	4	5
Family
Friends
Co-Workers
Give Love
Receive Love
Other

Group 5: Sleep

	1	2	3	4	5
Overall Quality
Hard to Fall Asleep
Wakes Frequently

1=Never / 5=Always

Group 6: Tendency Towards

	1	2	3	4	5
Anger
Depression
Anxiety
Frustration
Fear
Panic
Crying
Highly Sensitive
Phobias

Group 7: Self Care

	1	2	3	4	5
Spiritual Development
Spiritual Relationship
Invest in Your Passion
Exercise
Pray
Meditate
Get a Massage
Belly Laugh
Negative Self-talk
Chatter in Your Brain
Addictive Personality
Over Analyze
Intimacy Issues
Suppress Emotions
Past Regrets

Top 3 symptoms to work on during the next 6 weeks:
1.
2.
3.
Should be Empty: