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Screening Quiz

Please answer the questions in this quiz to give us a sense of the issues concerning you. PLEASE RESPOND TO THESE QUESTIONS IN RELATION TO THE PAST TWO TO FOUR WEEKS. Required fields are marked *.

An email that we can use to contact you and set up an appointment.

A phone number where we can contact you to set up an appointment.

Have you had trouble getting to sleep at night?
Have you had at least 7 hours of uninterrupted sleep per night?
Have you lived alone recently?
Have you exercised at least 3x per week?
Have you experienced satisfying relationships with the people you care about?
In general, have you managed stress well?
Have you found yourself worrying about things often, or felt more nervous or anxious?
Have you struggled with mental fog or problems with attention?
Have you experienced whiplash, concussion, or head injury?
Eaten fruits and vegetables on a regular basis?
Have you eaten in the past 2-4 weeks any processed foods? (i.e.: fast food)
Have you/ do you considered you’re eating habits as healthy?
Have you had a happy, healthy childhood with consistent parenting?
Have you regularly experienced sufficient energy to get tasks completed on a day-to-day basis?
Have you been feeling upbeat and positive lately?
Have you been feeling irritable more days than not?
Have you been living close to major highways or very busy roadways?
Have you regularly experienced chronic pain?
Have you often worried about having enough money to look after yourself and/or your family?
Have you been taking medication for mental health?
Have you used substances such as alcohol or other drugs as part of your daily routine?
Have you thought about ending your life in the past 2 months?
Have you felt concerned about the safety of yourself or others in your life?
Have you experienced any significant life changes or loss?
Have you felt that your spiritual needs are being met?
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