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(Make sure to fill out all the fields marked with an asterisk before completing the form)
Final Questionnaire
*
Full Name
*
Initials
*
Date
*
Phone
*
Age
*
Male/Female
*
Select One
Male
Female
E-mail
*
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 USAGE 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?
*
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 having 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 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.
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