Diagnosis Survey Form

Name

Email

Phone-number

Age

Which option best describes you? Student Intern Professional Other

When did symptoms appear?

All symptoms you are currently experiencing(Check all that apply) Excessive anger, hostility or violence Confused thinking or reduced ability to concentrate Excessive fears or worries, or extreme feelings of guilt Feeling sad or down Increased sensitivity(sights, sounds, smells) Inability to cope with daily problems or stress Easily distracted Vomitting, coughing, or sore throat Headache Shortness of breath

Describe any thoughts or emotions that stood out to you today: