Skip to content
Menu
Addictive/Cravings: Get help here
Home
Meet the Doctors: Naturopathic Physician and Chiropractor
Natural Medical Care & Treatment
Scientific Quantum Long Distance Energy Healing
Testimonials
Forms, Payment & Contact
Final Questionnaire
Final Questionnaire
Full Name
*
Full Name
First
First
Last
Last
Initials
*
Date
*
Age
*
Male/Female
*
Select One
Male
Female
Phone
*
Email
*
Please rate CRAVINGS from 1 to 5.
1 = Not at all. 2 = Occasionally. 3 = Can do without it. 4 = Must have it daily. 5 = Constantly.
Sugar
*
1
2
3
4
5
Caffeine
*
1
2
3
4
5
Chocolate
*
1
2
3
4
5
Ice Cream
*
1
2
3
4
5
Cookies
*
1
2
3
4
5
Alcohol
*
1
2
3
4
5
Candy
*
1
2
3
4
5
Marijuana
*
1
2
3
4
5
Tabacco
*
1
2
3
4
5
Diet Soda Pop
*
1
2
3
4
5
Soda Pop
*
1
2
3
4
5
Cake
*
1
2
3
4
5
Opioids
*
1
2
3
4
5
Heroine
*
1
2
3
4
5
Cocaine
*
1
2
3
4
5
Crystal Meth
*
1
2
3
4
5
Crack
*
1
2
3
4
5
Drugs
*
1
2
3
4
5
Other
Please rate CRAVINGS from 1 to 5.
1 = Not at all. 2 = Occasionally. 3 = Can do without it. 4 = Must have it daily. 5 = Constantly.
Sugar
*
1
2
3
4
5
Caffeine
*
1
2
3
4
5
Chocolate
*
1
2
3
4
5
Ice Cream
*
1
2
3
4
5
Cookies
*
1
2
3
4
5
Alcohol
*
1
2
3
4
5
Candy
*
1
2
3
4
5
Marijuana
*
1
2
3
4
5
Tabacco
*
1
2
3
4
5
Diet Soda Pop
*
1
2
3
4
5
Soda Pop
*
1
2
3
4
5
Cake
*
1
2
3
4
5
Opioids
*
1
2
3
4
5
Heroine
*
1
2
3
4
5
Cocaine
*
1
2
3
4
5
Crystal Meth
*
1
2
3
4
5
Crack
*
1
2
3
4
5
Drugs
*
1
2
3
4
5
Other
How long have you been sober from ALCOHOL?*
*
Select One
Never Used Alcohol
Less than 7 days
7 - 21 days
22 - 30 days
31 - 60 days
61 - 364 days
1 - 3 years
More than 3 years
Do you still have cravings for ALCOHOL?
*
Select One
Yes
No
How long have you been sober from DRUGS?
*
Select One
Never Used Drugs
Less than 7 days
7 - 21 days
22 - 30 days
31 - 60 days
61 - 364 days
1 - 3 years
More than 3 years
Do you still having cravings for DRUGS?
*
Select One
Yes
No
Please comment on your experience
*
I give my permission to use my answers and comments on any future products and social media using my first name, first name and last initial or initials.
Please put your initials below
*
If the form does not go through, double-check that you completed all the fields marked with an asterisk as they are required.
If you are human, leave this field blank.
Submit
Back To Top
