LIFESTYLE SURVEY
1. Whenever you have stopped drinking or using drugs for more than a couple of days, have
you experienced: (Check all that apply)
No change
Anxiety
Depression
Trouble sleeping
Shakiness
Irritability
Moodiness
Nausea/Vomiting
Seizures
Hallucinations
Paranoia
Body Aches/Pain
2. When you have gambled:
Have you ever felt the need to bet more and more money?
Have you ever lied to people important to you about your gambling?
Yes
No
3. When you have gone shopping or are spending money:
Have you ever spent money to try to change the way you feel?
Have you spent money you really couldn’t afford to spend?
Have you ever lied to people important to you about your spending?
Yes
No
4. In regard to your past or present eating/dieting habits:
Have people close to you ever expressed concern about your eating?
Yes
No
5. With regard to your past or present sexual activity:
Yes
Have you ever engaged in sexual activity for money, drugs or to survive?
Have you ever lied about or hidden your sexual activities from family/friends?
No
6. In regards to your computer use?
Have you ever failed to fulfill important obligations at work, at home or
with friends because of the time you spend on the computer?
Have you ever lied about or hidden your activities while on line or the
amount of time you spend on the computer from family or friends?
No
Yes
7. Have you experienced any of the following?
8.
Thinking about ending your life
Considering harming others
Prior suicide
attempts
Violent thoughts
Violent behavior
Chronic depression
Recent major life changes
Emotional trauma
Acute anxiety
Abuse
Social isolation
Significant losses
Difficulty coping
Chronic fears
Obsessive thoughts or behaviors
Seeing or hearing things that others don’t see or
hear
Fears of going crazy
Significant changes in eating or sleeping habits
Past domestic violence
Current domestic violence
Please list your strengths and or things you do well: ____________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list things you do to cope or feel better: ________________________________________
______________________________________________________________________________
______________________________________________________________________________
How do you learn best? (Check any/all that apply)
Seeing
Hearing
Hands-on
Other___________
Name: ______________________________ Date: __________