If yes, please indicate:
Do you have any of the following specific conditions. If any of these above-mentioned conditions change during the course of this trial, it is imperative that you contact your therapist immediately.
Choose one to three symptoms (physical, mental or energetic) which bother you the most. Now consider the severity of each symptom (over the last week or month) and score from 1 - 10, 1 being not a problem and 10 being very severe.
Now choose one activity (physical, social or mental) that is important to you that any of your symptoms prevent you from doing. Score how bad it has been in the last week or month.
How would you rate your general feeling of well-being out of 10 (1 – not well, 10 – feeling great) during the last:
By ticking the below box, I confirm that I have supplied the most up to date information according to my knowledge on the Initial screening form.