Patient's Form - BalanSoul

Patients Intake - Revised 7 Mar 2023

First Name

Last Name

Patient Gender

Patient Age

Symptom Severity / Frequency
0 = Never
1 = Mild or Infrequent Symptoms (twice per week or less)
2 = Moderate or Frequent Symptoms (3-6 times a week)
3 = Severe or Daily Symptoms

Tip
If your response is Never, you do not need to click and you can skip that question. If however, you do change your mind for example from Mild (1) to Never (0) you will need to click.

Diagnosed with major depression, bipolar disorder / manic depression

Yes

Feel angry, aggressive - short emotional fuse - aggressive with alcohol

Mild

Moderate

Severe

Never

Unexpected weight loss or gain more than 5% of body weight in a month

Yes

Do you have a negative reaction to stressful situations; Worry or dwell over things for an extended period, for example - Family problems - Financial problems - Stress at work or home - Things you haven’t done before - Relationship problems with a partner - Relationship breakup

Mild

Moderate

Severe

Never

Constantly worry about your body size

Mild

Moderate

Severe

Never

Crave or engage in behaviour - Frequent and / or excess alcohol use, recreational drug use- Gambling, extreme sports

Yes

Diagnosed with - ALS, Multiple Sclerosis, Dementia, Alzheimer's,- Parkinson’s, Huntington’s, Myasthenia gravis, Tardive dyskinesia

Yes

Previously used large amounts of stimulants

Yes

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Patient’s Form