mood questionnaire

1. name: *
2. date: *
Please select the appropriate number 0-3 on all questions below.  Please answer to the best of your ability.  0 as the least/lowest/never to 3 as the most/highest/always.
section 1 - ST
3. how high is your stress level? *
4. how often do you feel that you have something that must be done? *
5. do you feel you never have time for yourself? *
section 2 - BS
6. how often do you get irritable, shaky, or have lightheadedness between meals? *
7. how often do you feel energized after eating? *
8. how often do you have difficulty eating large meals in the morning? *
9. how often does your energy level drop in the afternoon? *
10. how often do you crave sugar and sweets in the afternoon? *
11. how often do you wake up in the middle of the night? *
12. how often do you have difficulty concentrating before eating? *
13. how often do you depend on coffee to keep yourself going? *
14. how often do you feel agitated, easily upset, and nervous between meals? *
15. do you get fatigued after meals? *
16. do you crave sugar and sweets after meals? *
17. do you feel you need stimulants such as coffee after meals? *
18. do you have difficulty losing weight? *
19. do you have weight gain under stress? *
20. do you have difficulty falling asleep? *
section 3 - SR
21. are you losing your pleasure in hobbies and interests? *
22. how often do you feel overwhelmed with ideas to manage? *
23. how often do you have feelings of inner rage (anger)? *
24. how often do you have feelings of paranoia? *
25. how often do you feel sad or down for no reason? *
26. how often do you feel like you are not enjoying life? *
27. how often do you feel you lack artistic appreciation? *
28. how much are you losing your enjoyment of friendships and relationships? *
29. how often do you have difficulty falling into deep restful sleep? *
30. how often do you feel more susceptible to pain? *
section 4 - D
31. how often do you have feelings of hopelessness or worthlessness? *
32. how often do you have self-destructive thoughts? *
33. how often do you have an inability to handle stress? *
34. how often do you have anger and aggression while under stress? *
35. how often do you feel you are not rested even after long hours of sleep? *
36. how often do you prefer to isolate yourself from others? *
37. how easily are you distracted from your tasks or have a hard time finishing? *
38. how often do you feel the need to consume caffeine to stay alert? *
39. how often do you feel your libido has been decreased? *
section 5 - G
40. how often do you feel anxious or panic for no reason? *
41. how often do you feel knots in your stomach? *
42. how often do you have feelings of being overwhelmed for no reason? *
43. how often do you have feelings of guilt about everyday decisions? *
44. how often does your mind feel restless? *
45. how difficult is it to turn your mind off when you want to relax? *
46. how often do you have disorganized attention? *
47. how often do you worry about things you were not worried about before? *
48. how often do you have feelings of inner tension and inner excitability? *
section 6 - ACH
49. do you feel your visual memory (shapes and images) is decreased? *
50. do you feel your verbal memory is decreased? *
51. do you have memory lapses? *
52. has your creativity been decreased? *
53. has your comprehension been diminished? *
54. do you have difficulty recognizing objects & faces? *
55. do you feel like your opinion about yourself has changed? *
Nutrition therapy is not intended as a diagnosis, treatment, prescription, or cure for any disease, mental or physical, and is not intended as a substitute for regular medical care.  This questionnaire is for informational purposes only.