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Initial Questionnaire
Name
First
*
Last
*
Date
*
Your Initials
*
Age
*
Male/Female
*
Email (Please print legibly)
*
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
Crack
*
1
2
3
4
5
Soda/Pop
*
1
2
3
4
5
Caffeine
*
1
2
3
4
5
Chrystal Meth
*
1
2
3
4
5
Sugar
*
1
2
3
4
5
Chocolate
*
1
2
3
4
5
Heroin
*
1
2
3
4
5
Tobacco
*
1
2
3
4
5
Cocaine
*
1
2
3
4
5
Marijuana
*
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
Crack
*
1
2
3
4
5
Soda/Pop
*
1
2
3
4
5
Caffeine
*
1
2
3
4
5
Chrystal Meth
*
1
2
3
4
5
Sugar
*
1
2
3
4
5
Chocolate
*
1
2
3
4
5
Heroin
*
1
2
3
4
5
Tobacco
*
1
2
3
4
5
Cocaine
*
1
2
3
4
5
Marijuana
*
1
2
3
4
5
Other
How long have you been sober from
ALCOHOL
?
*
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 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
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.
Please Initials
*
All information is confidential. Only first name, first name and last initial or initials will be used to compile data.
Please initials
*
I agree to fill out the FINAL QUESTIONNAIRE within 45 days. Please Initials
*
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