PG 7 - HOUSE OF BREAD TRAINING CENTER

HOUSE OF BREAD TRAINING CENTER

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Adult Questionnaire Page 7

This page asks questions about your attitude, your grandparents,
hospitalizations, and medications.

CATEGORY B : PART 1

* Indicates required field

YOUR Name *

First

Last

1A. ARE YOU EASILY FRUSTRATED? *

YES NO

1B. DO YOU SHOW IT OR BURY IT? *

SHOW BURY

2. ARE YOU: *

AN ANXIOUS PERSON A WORRIER GET DEPRESSED

3. DID EITHER OF YOUR PARENTS OR GRANDPARENTS SUFFER FROM DEPRESSION? *

YES NO

3A. CHECK WHICH PARENT OR GRANDPARENT SUFFERED FROM DEPRESSION *

FATHER MOTHER GRANDMOTHER GRANDFATHER

4. HAVE YOU OR HAS ANY PARENT, BROTHER, SISTER, OR GRANDPARENT SUFFERED FROM ACUTE NERVOUSNESS OR A MENTAL PROBLEM, SUCH AS SCHIZOPHRENIA, BIPOLAR DISORDER, OR OBESSIVE COMPULSIVE DISORDER? *

YES NO

4A. WHO? PROBLEM? *

5A. HAVE YOU PERSONALLY EVER HAD HOSPITALIZATION FOR PSYCHIATRIC TREATMENT? *

YES NO

5B. HAVE YOU PERSONALLY EVER HAD OTHER HOSPITALIZATIONS? *

YES NO

5C. HAVE YOU PERSONALLY EVER HAD SHOCK TREATMENTS? *

YES NO

5D. HAVE YOU PERSONALLY EVER HAD PSYCHOANALYSIS? *

YES NO

5E. HAVE YOU PERSONALLY EVER BEEN UNDER ANESTHESIA? *

YES NO

5F. HAVE YOU PERSONALLY EVER BEEN INTOXICATED (ALCOHOL)? *

YES NO

5G. HAVE YOU PERSONALLY EVER USED DRUGS INDUCING A PASSIVE-MIND STATE? (PRESCRIPTION OR NON-PRESCRIPTION) *

YES NO

5H. HAVE YOU PERSONALLY EVER HAD A FEVER WITH DELIRUM? *

YES NO

5I. HAVE YOU PERSONALLY EVER BEEN UNCONSCIOUS? *

YES NO

6A. HAVE YOU EVER BEEN HYPNOTIZED? *

YES NO

6B. IF SO, WHEN AND WHY? *

7A. ARE YOU CURRENTLY TAKING ANY MEDICATION FOR DEPRESSION, ANXIETY OR PAIN, OR AN ANTI-PSYCHOTIC DRUG? *

YES NO

7B. IF SO, WHAT ARE YOU TAKING AND HOW OFTEN ARE YOU TAKING IT? *

8. SINCE YOU HAVE BEEN TAKING IT, DO YOU HAVE DIFFICULTY CONCENTRATING AND FOCUSING OR IS IT EASIER? *

HAVE DIFFICULTY IT'S EASIER

Submit

REMEMBER TO SUBMIT &

CLICK HERE FOR PAGE 8 OF 18

House of Bread Training Center (DBA) House of Bread,

Inc. is a registered 501(C) (3) Non-Profit Organization

(EIN 82-0571018)

House of Bread

Mailing Address:

P.O. Box 1509

Griffin, Ga 30224

Current Physical Address:

1311 Kennedy Drive

Griffin, Ga 30224

Click to Here to Make a Donation.
Thank you for your support!

Adult Questionnaire Page 7

CATEGORY B : PART 1

REMEMBER TO SUBMIT &​CLICK HERE FOR PAGE 8 OF 18

House of Bread Training Center (DBA) House of Bread,Inc. is a registered 501(C) (3) Non-Profit Organization ​(EIN 82-0571018)

House of BreadMailing Address:P.O. Box 1509 Griffin, Ga 30224Current Physical Address:1311 Kennedy Drive​Griffin, Ga 30224

REMEMBER TO SUBMIT &

CLICK HERE FOR PAGE 8 OF 18

House of Bread Training Center (DBA) House of Bread,

Inc. is a registered 501(C) (3) Non-Profit Organization

(EIN 82-0571018)

House of Bread

Mailing Address:

P.O. Box 1509

Griffin, Ga 30224

Current Physical Address:

1311 Kennedy Drive

Griffin, Ga 30224