General Health Vitality Questionnaire

This questionnaire is confidential! The questions that you answer and the results of this test will only be seen by you and are not sent to our office nor will be reviewed by our office. Each response that you give will be assessed by our exclusive Health Evaluation Program and your results will be given at the conclusion of this test. Please feel free to contact our office if you have any questions or would like additional assistance with your results.

Scoring: in front of each question enter the following score:
4 ....... If you very often or constantly have this issue.
3 ....... If you often have this issue.
2 ....... If you occasionally have this issue.
1 ....... If you seldom have this issue.
0 ....... If you never have this issue.

Fill out the following form completely and then click on "Get My Results" in order to see the results of your test.

Type Your Full Name

0	1	2	3	4	How Often Do You...
					1.) Experience indifference (don't care)?
					2.) Lose your sense of humor / take life too seriously?
					3.) Experience doubt or indecision?
					4.) Experience worry or anxiety?
					5.) Feel over cautious or pessimistic?
					6.) Lack self confidence or feel low self esteem?
					7.) Experience stress or feel nervous or tense?
					8.) Feel irritable or oversensitive?
					9.) Experience difficulty concentrating or loss of clear thought?
					10.) Experience inadequate energy (fatigue)?
					11.) Have coffee, tea, tobacco, sugar or other stimulants as a pick me up?
					12.) Experience nervous indigestion?
					13.) Experience loss of sex drive?
					14.) Experience difficulty sleeping?
					15.) Experience difficulty getting up in the morning?
					16.) Feel run down?
					17.) Feel depressed?
					18.) Feel like crying for no reason?
					19.) Find it difficult to sit quietly (without fidgeting, talking, reading, watching TV, etc.)?
					20.) Find it difficult to express your feelings?
					21.) Experience rapid heart beat or panic?
					22.) Feel moody?
					23.) Feel suicidal or wonder whether life is worth living?
					24.) Have anxiety about not having enough money?
					25.) Feel that you have ill health?
					26.) Fear criticism?
					27.) Fear loss of love?
					28.) Fear old age or death?
					29.) Feel "something is the matter with me" but don't know what?
					30.) Think you might be going crazy (losing it)?