Drug Rehabilitation Process: Initial Questionnaire

Addictive/Cravings: Get help here
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Initial Questionnaire

Full Name *

Full Name

First

Last

Initials *

Date *

Age *

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 *

Caffeine *

Chocolate *

Ice Cream *

Cookies *

Alcohol *

Candy *

Marijuana *

Tabacco *

Diet Soda Pop *

Soda Pop *

Cake *

Opioids *

Heroine *

Cocaine *

Crystal Meth *

Crack *

Drugs *

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 *

Caffeine *

Chocolate *

Ice Cream *

Cookies *

Alcohol *

Candy *

Marijuana *

Tabacco *

Diet Soda Pop *

Soda Pop *

Cake *

Opioids *

Heroine *

Cocaine *

Crystal Meth *

Crack *

Drugs *

Other

This combination homeopathic remedy has not been evaluated by the Food and Drug Administration.

This product is not intended to diagnose, treat, cure of prevent any disease.

All information is confidential. Only first name or first name and last initial or initials will be used to compile data.I have read the above statements and agree.

Please put your initials below *

I agree to fill out the FINAL QUESTIONNAIRE within 45 days. 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.

Scientific Quantum Remote Healing » Drug Rehabilitation Process: Initial Questionnaire