General Life Experience Worksheet 3 of 4

First Name

Last Name

Email

1. Have you ever had any frightening, traumatizing or upsetting life experiences that have resulted in persistent and/or recurring thoughts of the experiences?

2.  Do you, or have you had persistent and/or recurring nightmares related to the experiences in question 1?

3. Do you struggle with controlling negative thoughts related to or go out of your way to avoid similar situations that remind you of the experiences related to question 1?

4. Do you feel numb or detached from family, friends, other people in general or your surrounding environments related to any of the previous questions?

Over the last 30 days, how often have you been troubled by the following problems?
(Select the answer that best applies)

5. Having difficulty concentrating on things, such as reading or watching TV?

6. Don’t feel hungry, or over eat?

7. Little interest or pleasure in doing things you used to enjoy?

8. Feeling depressed, emotionally down, or hopeless?

9. Moving or speaking so slowly other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?

10. Feeling bad about yourself, low self-confidence, or that you have let yourself or others down?

11. Feeling tired or have low energy throughout the day?

12. Trouble falling asleep, staying asleep, or sleeping too much?

13. Thoughts that you would be better off dead, or of hurting yourself?

14. Do you have what you think are good ideas but lack motivation or give up before achieving your goals or desired outcomes?

15. Have you tried more than one self-help methodology?

16. If you have tried more than one book or online self-help program, how many have you tried?

17. Have you explored general medical, specialist, counseling, coaching, practitioners, or other solutions to help you improve your mental and emotional health and quality of life?

18. If so, which methodologies have offered the best results that still help you today?
(Select all that apply)

19. Do you still have deep-rooted emotional issues that you would like to get rid of?

20. If a reliable results-based program was available at a reasonable cost, would you be interested in taking the program in the next 30 days?

Please enter a value from 1 to 100 on how this survey makes you feel today: