Nervous System Wellness Survey
Help us understand your current nervous system health and wellness by completing this survey.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Which of the following symptoms have you experienced in the past month? (Select all that apply)
*
Headaches or migraines
Tingling or numbness
Dizziness or lightheadedness
Difficulty concentrating
Muscle weakness or spasms
Sleep disturbances
Other
How would you rate your current nervous system wellness?
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
How often do you practice stress management techniques (e.g., meditation, deep breathing, yoga)?
*
Please Select
Daily
Several times a week
Once a week
Rarely
Never
Please describe any other concerns or comments about your nervous system wellness.
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