Psychology Checklist
Please fill out this checklist to help us understand your psychological state.
Physical Symptoms
Do you experience any physical symptoms?
Yes
No
Please describe the physical symptoms you are experiencing
Mental Health
Have you been diagnosed with any mental health conditions?
Yes
No
Please list any diagnosed mental health conditions
Emotional State
On a scale of 1 to 10, how would you rate your current emotional state?
1 (Very Low)
1
2
3
4
5
6
7
8
9
10 (Very High)
10
1 is 1 (Very Low), 10 is 10 (Very High)
What emotions are you experiencing the most?
Stress Level
How stressed do you feel on a scale of 1 to 10?
1 (Not Stressed)
1
2
3
4
5
6
7
8
9
10 (Extremely Stressed)
10
1 is 1 (Not Stressed), 10 is 10 (Extremely Stressed)
What are the main sources of stress in your life?
Sleep Patterns
How would you describe your sleep patterns?
Good
Fair
Poor
Additional Comments
Submit
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