If yes, how many? Please list their ages.
Is there anything stressful about your current work?
If you are currently taking any prescription medications, please list each medication & the reason.
Please describe your faith or belief.
If any area checked "Yes," please provide any details that are important or useful for me to know
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Provide who, where, when, and other information. If not applicable please write N/A.
Looking back over this list one more time, please self-reflect and suggest some ways in which a change in your own behavior might improve your satisfaction in any of the areas related to 'Very Unsatisfied' or 'A little Unsatisfied'
