Friendships: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – – Financial situation: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – – Physical health: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – – Anxiety level / nerves: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – – Mood: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – – Eating habits: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – – Sleeping habits: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – – Sexual functioning: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – –
Friendships: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable Financial situation: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable Physical health: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable Anxiety level / nerves: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable Mood: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable Eating habits: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable Sleeping habits: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable Sexual functioning: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable
adult-intake-form-ud.docx