CONSUMER QUESTIONNAIRE
NAME: NAME: Last, First, Middle
CLIENT ID #:
SSN#:
DATE:
Instructions: Please check any item which you have ever experienced or are currently experiencing.
Marital stress
Too much alcohol
Other family problems
Sexual problems
Other relationship problems
Less energy than usual
Problems at work/school
Very talkative
Health problems
Restless/can’t sit still
Financial problems
Nervous/tense
Legal problems
Panicky
Sad/depressed
Shaky/trembling
Loss of appetite
Hard to trust anyone
Loss of weight
Problems controlling my thoughts
Weight gain
Too much worry
Difficulty sleeping
Too many fears
Difficulty concentrating
Feeling guilty
Quick change of moods
Feeling angry/ frustrated
Problems with controlling anger or urges
Nightmares
Feeling suicidal
Too much pain
Feeling worthless
Memory problems
Drawing away from people
See/hear strange things
Lack of interest/enjoyment
Feeling others are out to get me
Too many drugs
Watched/talked about by others
Comments:
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Consumer’s Printed Name
TIER
GEN:655:N:01/13
__________________________________
Consumer’s Signature
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For Professional Use Only