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Final Questionnaire
(Make sure to fill out all the fields marked with an asterisk before completing the form)
Name (First and Last)
*
Initials
*
Date
*
Phone
*
Age
*
Male/Female
*
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.
Alcohol
*
1
2
3
4
5
Caffeine
*
1
2
3
4
5
Chocolate
*
1
2
3
4
5
Chrystal Meth
*
1
2
3
4
5
Cocaine
*
1
2
3
4
5
Crack
*
1
2
3
4
5
Heroin
*
1
2
3
4
5
Marijuana
*
1
2
3
4
5
Opioids
*
1
2
3
4
5
Soda/Pop
*
1
2
3
4
5
Sugar
*
1
2
3
4
5
Tobacco
*
1
2
3
4
5
Other
Please rate
USAGE
from 1 to 5.
1 = Not at all. 2 = Occasionally. 3 = Can do without it. 4 = Must have it daily . 5 = Constantly.
Alcohol
*
1
2
3
4
5
Caffeine
*
1
2
3
4
5
Chocolate
*
1
2
3
4
5
Chrystal Meth
*
1
2
3
4
5
Cocaine
*
1
2
3
4
5
Crack
*
1
2
3
4
5
Heroin
*
1
2
3
4
5
Marijuana
*
1
2
3
4
5
Opioids
*
1
2
3
4
5
Soda/Pop
*
1
2
3
4
5
Sugar
*
1
2
3
4
5
Tobacco
*
1
2
3
4
5
Other
How long have you been sober from
ALCOHOL
?
*
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?
*
Yes
No
How long have you been sober from
DRUGS
?
*
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 have CRAVINGS for drugs?
*
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 initials
*
If the form doesn't go through, double-check that you completed all the fields marked with an asterisk as they're required.
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