Self-Diagnosis Behavior Survey Form
Please complete this survey to understand your behavior patterns.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age Group
*
Please Select
Under 18
18-25
26-35
36-45
46-60
Above 60
Gender
*
Please Select
Male
Female
Other
Do you often feel anxious?
*
Never
Rarely
Sometimes
Often
Always
Do you experience mood swings?
*
Never
Rarely
Sometimes
Often
Always
How frequently do you find yourself procrastinating?
*
Never
Rarely
Sometimes
Often
Always
Stress Level Today
*
1
2
3
4
5
Do you have trouble sleeping?
*
Never
Rarely
Sometimes
Often
Always
Which of these behaviors do you recognize? (Select all that apply)
Avoiding responsibilities
Overeating
Sharpening focus on hobbies
Sleeping excessively
Engaging in social activities
Additional comments or notes
Submit
Should be Empty: