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CHANGE YOUR PERSPECTIVE OF LIFE WITH: NEURO-LINGUISTIC PROGRAMMING
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Name
*
Last Name
*
Sex:
Male
Female
Address
Email
*
State / Province
Age
18-30
31-49
49+
Birth date (YYYY-MM-DD)
Please indicate the emotional conditions and symptoms you have experienced in the last 6 months
Write down everything you feel related to fears, sadness, and emotional pain you are experiencing
Are you aware of all the symptoms you are experiencing?
Yes
No
Please write down all the medicines you are taking, including dosage and frequency.
Have you received psychological treatment?
Yes
No
The patient has been diagnosed with any of the following symptoms:
Anxiety
Depression
Screams frequently
Sadness
Drink alcohol
Smoke cigarette
Please provide all the healing procedures and the dates they were performed.
The patient has been diagnosed with any of the following symptoms
Getting angry easily
Repeating the same mistakes all the time
Blaming others for everything that happens to you
Not taking responsibility for your actions
Using foul language
Trichotillomania (hair-pulling)
Constantly scratching your nose
Smoking cigarettes
Nail-biting
Constantly pulling your hair
Watching too much television
Eating fast food or junk food
Alcohol (if you think you may be an alcoholic, please seek professional help)
Compulsive shopping
Unnecessary expenses on credit cards
Excessive use of Facebook
Excessive consumption of white sugar
Drinking too much soda
Obsessively checking your phone/tablet
Spending too much time playing video games
Talking with your mouth full
Talking to yourself excessively
Frequently expressing yourself in the wrong way
Excessive pornography viewing
Constantly lying
Grinding your teeth in public
Forgetting to shave
Spending too much time in nightclubs
Being self-centered (behaving with egocentrism and not considering others)
Using your phone in bed frequently
Negative self-talk / self-criticism
Saying "yes" to everything
Getting easily distracted
Procrastinating
Excessive use of devices at night
Spending too much time on social media
Speaking negatively and self-criticizing
Sleeping until very late
Obsessively checking your hair/eyebrows/makeup/nails
Watching TV right after work
Repeating the same thing over and over again
Being afraid to try something new out of fear of failure
Nymphomania (Female)/Satyriasis (Male)
Compulsive gambling
Falling asleep in class/work
Making excuses to skip the gym
Slouching while walking
Masturbating too frequently
Kleptomania (Compulsive stealing)
Yelling when speaking
Lacking self-confidence
Talking excessively in class/work
Not being grateful
Having a confrontational temperament
Always needing to be right
Not getting enough sleep
Having repetitive negative thoughts
Hatred (Being resentful)
Being arrogant
Constantly swearing
Being vengeful (Seeking revenge)
Being a troublemaker (Someone who harms or damages or spoils things around them)
Overeating when stressed.
Constantly interfering in other people's conversations.
Not listening to others and monopolizing conversations
Being disorganized and not keeping your spaces tidy
Procrastinating important decision-making.
Being unpunctual and arriving late to appointments.
Leaving lights on unnecessarily and wasting energy
Ignoring personal or dental hygiene
Not cleaning up after your pet in public places
Constantly complaining without taking steps to solve problems
Avoiding physical activity and leading a sedentary lifestyle
Being negative and pessimistic in all situations
Speaking loudly on the phone in quiet places
Spreading gossip or divulging confidential information
Not showing empathy or support towards others
Spending too much time on games or mobile apps
Overeating outside of regular meals
Not brushing your teeth before bedtime
Using poor table manners or in social situations
Ignoring your personal finances not budgeting
Not taking care of your belongings and damaging items easily
Not being punctual with your responsibilities at work or school
Displaying negative body language, such as crossing your arms or frowning
Speaking too loudly in quiet places
Being overly critical of others without providing constructive support
Not following through on promises made to others
Not practicing gratitude or showing appreciation for the good things in your life
Avoiding eye contact during conversations
Spending too much time watching online content instead of productive activities
Not respecting others' personal boundaries
Being overly competitive and trying to outdo others in everything
Speaking ill of others behind their backs
Leaving things half-done or not completing tasks you've started
Not respecting others' personal space
Being negative on social media and spreading hate messages
Not respecting the environment, such as improperly disposing of trash
Having an attitude of superiority or arrogance
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