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Initial Assessment

Posted Jan 11 2009 3:43pm

 

 

Please take a few moments to answer these questions to the best of your ability prior to using CD

 

Answer each question according to the following scale:

                                      

1)     Never/ very rarely

2)     Rarely

3)     Occasionally

4)     Usually

5)     Always

 

About Your Stress

 

I feel relaxed                                       1      2      3      4      5

 

I sleep well at night                            1      2      3      4      5

 

I choose nutritious foods                     1      2      3      4      5

 

I am able to focus                                1      2      3      4      5

 

I am energetic                                      1      2      3      4      5

 

I am pain free                                      1      2      3      4      5

 

I have a feeling of well being              1      2      3      4      5

 

 

 

Personal Information (optional)

 

Age:                             18-30      31-50      51–70      70 +

 

Exercise per/week:      1-2      3-4      5-7

 

Gender:                       M / F

 

Occupation:

 

 

Thank you for taking the time to complete our questionnaire

 

 

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