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MONTHLY SURVEY

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Welcome back. Please fill in the form below and click submit when you are finished.

User Name

Email

1. Syptoms of Primary Complaint*

1	2	3	4	5	6	7	8	9	10

0 = None 10 = Severe

2. Level of Pain*

1	2	3	4	5	6	7	8	9	10

0 = None 10 = Severe

3. Anxiety level*

1	2	3	4	5	6	7	8	9	10

0 = None 10 = Severe

4. Quality of sleep*

1	2	3	4	5	6	7	8	9	10

0 = Terrible 10 = Excellent

5. Mood*

1	2	3	4	5	6	7	8	9	10

0 = Terrible 10 = Excellent

6. Energy Level*

1	2	3	4	5	6	7	8	9	10

0 = Very Low 10 = Very High

7. Overall Health*

1	2	3	4	5	6	7	8	9	10

0 = Worst Imaginable 10 = Best Imaginable

8. Over the past week, have you experienced any side effects ?*

Other - please specify

Your Current Medication*

Please choose*

Dosage (ml/day)*

Dosage (puffs/day)*

Dosage (grams/day)*

Have you changed your dosage?

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