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Initial Questionnaire
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
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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