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For an immediate free PERSONAL response from Dr. Gruen, please complete this form.
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Main Reason for Seeking Help.
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During the past month:  
1. Do you wake up at night or early in the morning and are unable to return to sleep? Seldom: Some: Often:
2. Do you have very restless sleep? Seldom: Some: Often:
3. Do you experience periods of loss of energy? Seldom: Some: Often:
4. Do you experience periods of decreased sex drive? Seldom: Some: Often:
5. Are there times when you are unable to enjoy life? Seldom: Some: Often:
6. Are there time when you withdraw from others? Seldom: Some: Often:
7. Are there times when you have strong thoughts about suicide? Seldom: Some: Often:
8. Loss of appetite? Seldom: Some: Often:
9. Memory Problems, forgetfulness, poor concentration? Seldom: Some: Often:
10a. Weight loss? yes no
How much in last month?
10b. Weight gain? yes no
How much in last month?
10c.Have you been trying to diet? yes no
11. Have you felt a decreased need for sleep? Seldom: Some: Often:
12. Increased sex drive? Seldom: Some: Often:
13. Increased energy? Seldom: Some: Often:
14. Have you felt so happy that people describe you as 'manic'? Seldom: Some: Often:
15. Can't get to sleep? Seldom: Some: Often:
16. Sudden episodes of nervousness or panic? Seldom: Some: Often:
17. Palpitations or rapid heartbeat? Seldom: Some: Often:
18. Fear of losing self-control? Seldom: Some: Often:
19. Shortness of breath? Seldom: Some: Often:
20. Strange or unusual thoughts? Seldom: Some: Often:
21. Hallucinations, hear voices, or see things that aren't there? Seldom: Some: Often:
22. Very peculiar experiences? Seldom: Some: Often:
23. Ready to explode? Seldom: Some: Often:
24. Thoughts of harming someone? Seldom: Some: Often:
25. Excessive use of alcohol/drugs? Seldom: Some: Often:
   
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