Neurochemistry Assessment Survey
Please answer the following questions to help assess your neurochemical-related traits and behaviors.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
How would you rate your overall mood in the past two weeks?
*
Very low
1
2
3
4
5
6
7
8
9
Very high
10
1 is Very low, 10 is Very high
How often have you experienced the following in the past month?
*
Rows
Never
Rarely
Sometimes
Often
Always
Difficulty falling asleep
1
2
3
4
5
Trouble focusing or concentrating
6
7
8
9
10
Low motivation or energy
11
12
13
14
15
Changes in appetite
16
17
18
19
20
Feeling anxious or restless
21
22
23
24
25
Do you regularly engage in any of the following activities? (Select all that apply)
Regular exercise
Meditation or mindfulness
Socializing with friends/family
Creative hobbies (art, music, writing, etc.)
None of the above
Other
Is there anything else you would like to share about your mood, focus, sleep, or overall well-being?
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