CUSTOMER SURVEY
Please fill in or check the circles to rate the severity of any of the following symptoms you may be experiencing. If none apply fill in or check n/a.
Are you experiencing...
Trouble falling asleep
Trouble staying asleep
Frequent stress or anxiety
Irritability & poor mood
Chronic pain & discomfort
Frequent illness
Lack of focus
Patient Information:
Name:
Contact Information:
Date of Birth:
Rate the severity of experience from 1 (least severe) to 5 (most severe) n/a 5 4 2 3 1 n/a 5 4 2 3 1 n/a 5 4 2 3 1 n/a 5 4 2 3 1 n/a 5 4 2 3 1 n/a 5 4 2 3 1 n/a 5 4 2 3 1
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