Did your health problem occur after a traumatic experience?

Do You Now Feel... What % of Time You Feel This Way?
1. Irritated?		YES	%
2. Resentment?		YES	%
3. Shock-Trauma?		YES	%
Unrequited Love?		YES	%
Overwhelmed?		YES	%
Guilt?		YES	%
4. Fear?		YES	%
5. Stuck?		YES	%
Holding Onto?		YES	%
6. Anger?		YES	%
Frustration?		YES	%
7. Grief?		YES	%
8. Vulnerable?		YES	%
9. Low Self-esteem?		YES	%
Rejection?		YES	%
10. Disgust?		YES	%
Despair?		YES	%
11. Confusion?		YES	%
Paranoia?		YES	%
12. Male - Reproductive?		YES	%
Unresponsive?		YES	%
13. Female - Reproductive?		YES	%
Unresponsive?		YES	%
Date:
First Name:
Last Name:
Age:
Email:

This survey is in no way attempting to diagnose or treat physical health conditions.