Are you experiencing any of the following physical symptoms:
check all that apply
Headaches/ Migraines
Neck, shoulders and or back pain
Indigestion, bloating, gurgling or epigastric pain
Skin rashes, eczema or dry skin
Easily catches colds/ infections
Sensitivity to drafts, feeling cold all the time
Insomnia or sleep that isn't restful
Tiredness, fatigue or low energy
Poor concentration or memory
Tachycardia/ chest palpitations
Chest tightness or pain
Asthma, wheezing or shortness of breath
Feeling of "lump in throat" with difficult emotions
Weight Gain/ loss
Loose stools or constipation
PMS including but not limited to: rib-side pain, cramps, irritability
Abnormal day time sweating or night sweats
Joint pain, stiffness
Dizziness, tinnitus or vertigo
Chronic cough, dry throat
Are you experiencing any of the following mental/ emotional symptoms:
check all that apply
Anxiety, panic or restlessness
Sadness, grieving or depression
Self-doubt
Hyper-vigilance or fear of safety
Detachment
Less sympathetic
Feeling misunderstood
Feeling unappreciated
Memory impairment
Intrusive thoughts, mental chatter
Feeling like there isn't enough time to do many of the things important for quality in a job
Being a hater
Bitterness, dry, joyless cynicism
Ruminating thoughts, Over-thinking, over-worrying
Are you experiencing any of the following behavioral symptoms:
check all that apply
Avoiding self-responsibility
Indecisiveness
Accident-prone
Self-medication with food/ substances/ shopping/sex/ TV
Poor boundaries
Difficulty giving and receiving feedback
Perfectionist tendencies resulting in missed deadlines
Basing self-esteem on service to others
Perpetuating Superwoman myth
Withdrawing and difficulty asking for help when overwhelmed
Difficulty receiving help
Compulsion to over-work, workaholism
Care-giver self-care symptoms
check all that apply
Sleep deprivation
Poor eating habits
Failure to exercise
Failure to stay in bed when ill
Postponement or failure to make medical appointments for self
Name
First Name
Last Name
Email