1A Can you recall a time in the last month where you felt so anxious that it impacted your day-to-day life?"
"1B: Do you feel you have experienced depression?
1C: Do you think you have experienced bipolar disorder?
1D In the past six months, would you describe your eating habits as “unhealthy”?
1E Have the people in your life expressed concern for how often you use substances such as weed and alcohol?
2A Do you ever feel as though you tend to worry about specific things that others may not perceive as worrisome? " "
2B Have you ever felt down, depressed, irritable, or hopeless so intensely that it affected day to day ' 'activities?
2C Have you ever experienced an over-inflated feeling of energy and self-importance (euphoria)?
2D Does the thought of food/eating food cause you feelings of stress or guilt?
2E When times get hard, do you look to drugs as a coping mechanism?
3A Do you tend to avoid people, places, and things that may trigger feelings of panic for you?
3B. Have you ever participated in riskier behavior (e.g., excessive spending, gambling, angry confrontations,"etc)
3C. Do you find it difficult to control impulsive or harmful behaviors?
3D. When you think of the word “food,” would you describe your immediate thoughts on it as stressful or " "panic-inducing?
3E. Does the need to use a substance tend to interrupt your day-to-day activities, such as school and/or work? " "
4a1. Can you recall a time in the last month where you felt so anxious that it impacted your day-to-day life?
4a2. Do you ever feel as though you tend to worry about specific things that others may not perceive as worrisome?
4a3. Do you tend to avoid people, places, and things that may trigger feelings of panic for you?
4a4. Do you tend to overthink events and plan for worst-case scenarios?
4a5. Do you ever feel tension or soreness in your muscles, even if you haven’t exercised?
4a6. Do you ever experience difficulty falling asleep, staying asleep, or having restless and unsatisfying sleep?
4b1. Have you experienced little interest or pleasure in doing things you used to enjoy?
4b2. Have you noticed that you have been sleeping too much or too little?
4c1. Have you gone through periods where you require less sleep and still feel energized?
4c2. Have you ever felt that your thoughts were racing so quickly it was hard to keep up with them?
4d1. Do you ever experience feelings of guilt after eating?
4d2. Do you fear being overweight?
4d3. Do you prefer eating alone and not in front of others?
4d4. Do you feel that food controls your life?
4e1. Do you tend to always have some of your preferred substance on hand or readily available?
5. Based on your answers, how long have you been experiencing these symptoms?
6. Based on your answers, how severe do you rate your symptoms? (1 being tolerable, 10 being incapacitating)