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Please be honest in your answers. THEY WILL NEVER BE SHARED WITH ANYONE. They are a means to help put together the perfect package for you.
In the mornings I feel . . .
When I think about going to work I . . .
Driving to work, people around me . . .
When I get home from work, the first thing I do is . . .
Before I go to bed, I . . .
Where does it hurt physically?
Head / Headache
Eyes
Ears
Neck
Shoulders
Back
Hips / Waist
Knees
Ankles / Feet
Internal Organs / Other
HOW OFTEN?
Never
Every once in a while
Sometimes
Regularly
Often
Constantly
How's your Spirit / Mood right now?
Always Happy, Upbeat, Chipper No Matter What
Realistic Yet Positive Perspective
Feeling A Little Better Than Yesterday
Bland / Don't Care / Whatever
Depressed but Hoping
Plain ole Depressed
Nobody Loves Me
What's your name?
WHAT'S THE BEST DAY FOR US TO TALK?
WHAT'S THE BEST TIME FOR US TO TALK?
Hours
01
02
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Minutes
00
15
30
45
AM
PM
What's your phone number?
What's your email address?
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