Using a scale of 1 to 10, with a low concern and 10 an extreme issue, rate the following:
_____ Personal Relationships _____ Physical Health _____ Mental Health _____ Emotional Health
_____ Spiritual Beliefs _____ Finances _____ Eating/Nutrition _____ Addiction
_____ Health _____ Anger _____ Anxiety _____ Panic Attacks
_____ Trauma _____ PTSD _____ Post Partum _____ Memory Problems
_____ History of Depression _____ Personal Direction _____ Headache/Pain _____ Fatigue
_____ Hormonal/Menopause _____ Allergies _____ Sleeping Issues _____ Major Life Changes
_____ Do you feel safe at home? _____ Other