Smiley Australia




My History - What I was like Before my Illness:

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Name:

Age Now:

Age When You Became Ill (Approx.)

Date form Completed:


Please indicate how often you experienced any of the following by selecting the appropriate boxes:


1. Migraines			Never Sometimes Often Don't Know

2. Headaches Never Sometimes Often Don't Know

3. Dizzy Spells on Standing Never Sometimes Often Don't Know

4. Dizzy Spells anytime Never Sometimes Often Don't Know

5. Tremors or Shakes Never Sometimes Often Don't Know

6. Heart Palpitations Never Sometimes Often Don't Know

7. High Blood Pressure Never Sometimes Often Don't Know

8. Low Blood Pressure Never Sometimes Often Don't Know

9. Worries Never Sometimes Often Don't Know

10. Anxiety Never Sometimes Often Don't Know

11. Stress Never Sometimes Often Don't Know

12. Nightmares/Bad Dreams Never Sometimes Often Don't Know

13. Difficulty Sleeping Never Sometimes Often Don't Know

14. Lack of Energy Never Sometimes Often Don't Know

15. Restlessness Never Sometimes Often Don't Know

16. Pacing Never Sometimes Often Don't Know

17. Thoughts About Suicide Never Sometimes Often Don't Know

18. Attempted Suicide Never Sometimes Often Don't Know

19. Low Self Esteem Never Sometimes Often Don't Know

20. Agitation Never Sometimes Often Don't Know

21. Aggression Never Sometimes Often Don't Know

22. Violence Never Sometimes Often Don't Know

23. Feeling Down Never Sometimes Often Don't Know

24. Feeling Up Never Sometimes Often Don't Know

25. Big Appetite Never Sometimes Often Don't Know

26. No Appetite Never Sometimes Often Don't Know

27. Confused Thinking Never Sometimes Often Don't Know

28. Difficulty Concentrating Never Sometimes Often Don't Know

29. Overweight Never Sometimes Often Don't Know

30. Underweight Never Sometimes Often Don't Know

31. Good Eyesight Never Sometimes Often Don't Know

32. Poor Eyesight Never Sometimes Often Don't Know

33. Blurred Vision Never Sometimes Often Don't Know

34. Normal Blood Sugar Never Sometimes Often Don't Know

35. High Blood Sugar Never Sometimes Often Don't Know

36. Low Blood Sugar Never Sometimes Often Don't Know

37. Sleep Apnoea Never Sometimes Often Don't Know

38. Nausea Never Sometimes Often Don't Know

39. Hallucinations (Visual) Never Sometimes Often Don't Know

40. Hallucinations (Auditory) Never Sometimes Often Don't Know

41. Everthing Tastes Bad Never Sometimes Often Don't Know

42. Everything Smells Bad Never Sometimes Often Don't Know

43. Seizures Never Sometimes Often Don't Know

44. Blackouts Never Sometimes Often Don't Know

45. Losing Time/Amnesia Never Sometimes Often Don't Know

46. Interest in Sex Never Sometimes Often Don't Know

47. Sexual Difficulties Never Sometimes Often Don't Know

48. Heartbeat Racing Never Sometimes Often Don't Know

49. Stomach Pain Never Sometimes Often Don't Know

50. Abdominal Pain Never Sometimes Often Don't Know

51. Constipation Never Sometimes Often Don't Know

52. Difficulty Swallowing Never Sometimes Often Don't Know

53. Good Memory Never Sometimes Often Don't Know

54. High Cholesterol Never Sometimes Often Don't Know

55. Healthy Diet Never Sometimes Often Don't Know

56. Played Sport Never Sometimes Regularly Don't Know

57. Physical Exercise Never Sometimes Regularly Don't Know

58. Hobbies Never Sometimes Often Don't Know

59. Active Social Life Never Sometimes Often Don't Know

60. Enjoy Shopping Never Sometimes Often Don't Know

61. Enjoy Reading Never Sometimes Often Don't Know

62. Personal Hygiene Never Sometimes Often Don't Know

63. Family Contact with Parents Never Sometimes Often Don't Know

64. Family Contact with SiblingsNever Sometimes Often Don't Know

65. Family Contact with Partner Never Sometimes Often Don't Know

66. Family Contact with ChildrenNever Sometimes Often Don't Know

67. Driving Vehicle Never Sometimes Often Don't Know

68. Employment Never Sometimes Steady Don't Know

69. Attended School/Education Never Sometimes Regularly Don't Know

70. Few Friends Yes No

71. Lots of Friends Yes No

72. Workmates Yes No

73. Family History of Depression Yes No

74. Family History of Bipolar Disorder Yes No

75. Family History of Schizophrenia Yes No

76. Family History of Mental Disorder Yes No

77. Family History of Epilepsy Yes No


Please add any comments or additional information in the box below:

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