General Mental and Health Information

Please rate the following on a scale of 1-10 (10 being best) and write in any comments:

Sleep
______________________________________________________________________

Energy Level
______________________________________________________________________

Appetite
______________________________________________________________________

Digestion
______________________________________________________________________

1) How would you rate your current physical health (please circle or underline)
Poor Unsatisfactory Satisfactory Good Very good

Please list any specific health problems you are currently experiencing:
____________________________________________________________________
____________________________________________________________________

2) How many times per week do you generally exercise? _________________

What types of exercise do you participate in? _______________________________

3) Are you currently experiencing overwhelming sadness, grief or depression?

___No ___Yes
! If yes, for approximately how long? ________________________

4) Are you currently experiencing anxiety, panic attacks or have phobias?

___No ___Yes
! If yes, when did you begin experiencing this? _______________________

5) Are you currently experiencing any chronic pain?

___No ___Yes
! If yes, please describe: ________________________________________

6) Do you drink alcohol more than once a week? ___No ___Yes

7) Are you currently in a romantic relationship?
___No ___Yes
! If yes, for how long? ____________
On a scale of 1-10, how would you rate your relationship? ____________

8) What significant life changes or stressful events have you experienced recently?

Additional Information:
1) Are you currently employed?
___No ___Yes
! If yes, what is your current employment situation? ____________________
____________________________________________________________
____________________________________________________________
! Do you enjoy your current work? Is there anything stressful about it? ____
____________________________________________________________
____________________________________________________________

2) Do you consider yourself to be spiritual or religious?

___No ___Yes
! If yes, describe your faith or belief:________________________________
____________________________________________________________

3) In case of emergency, please list who to contact:

Name: ______________________________________Relationship: _____________
Phone Number: ________________________________

4) What would you like to address or change through the use of GIM?

____________________________ ______________________________ _________

Clients Printed Name! Clients Signature! ! ! Date