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General Information

Birthday
Marital status
Single
Married
Divorced
Separated
Widow(er)
Cohabitating
Are you currently receiving psychiatric or psychological care?
Yes
No
Have you been in therapy before?
Yes, individual therapy
Yes, couples therapy
No
Have you previously taken psychiatric medication (antidepressants or other)?
Yes
No

Health information

What is your current state of health?
Poor
Adequate
Good
Do you have trouble sleeping?
No
I do not sleep enough
I have insomnia
I have nightmares or night terrors
I sleep more than usual
Do you have any problems related to eating habits or appetite?
No
Yes, I eat a lot
Yes, I eat very little
Yes, I restrict what I eat
Have you noticed a significant change in weight in the last 2 months?
Yes
No
Do you drink alcohol regularly?
Yes
No
How often do you use recreational drugs?
Daily
Weekly
Monthly
Occasionally
Never
Have you had suicidal thoughts recently?
Frequently
Occasionally
Rarely
Never
Have you had suicidal thoughts in the past?
Frequently
Occasionally
Rarely
Never
Are you currently in one (or more) romantic relationships?
Yes, in a monogamous relationship
Yes, in two or more non-monogamous relationships
No, I am not currently dating
Have you experienced .....?

Other information

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