Q.1
please fill in the following information
Title
First Name
Last Name
Q.2
enter your email address
(e.g. john@example.com)
Q.3
What is your diagnosis?
(e.g. john@example.com)
Q.4
Date of onset
MM
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
/
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
Q.5
Are you satisfied with your curent treatment
*
You can enter some information about this question here.
Could be better
I have had to stop meds due to expense
I have stopped using medication
I regulate my meds by myself now.
No
Yes
Yes, but I do use alternative treaments as well
Q.6
How would you rate your curret state of mental health?
*
0-2: Very Poor
3-6: Getting by
7-10: Highly functioning
Q.7
Provide a short overview of your mental health history, including initial onset, genetic and environmental factors, physical complications, etc.
Q.8
How long have you been on medication? Please list all medications, qtys, side effect, resons for discontinuing
Q.9
What alternative treatments have you tried? Which have worked best for you?
Create your own free
online surveys
now!
Powered by
Surveydaddy