Stimulant Withdrawal Symptom Questionnaire Form
Please complete the Stimulant Withdrawal Symptom Questionnaire Form to help us understand your recent experiences. This form is for general self-assessment purposes only.
Full Name
First Name
Last Name
Date of Completion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate your overall energy level over the past week?
*
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 difficulty sleeping in the past week?
*
Never
Rarely
Sometimes
Often
Always
In the past week, how frequently have you felt irritable or anxious?
*
Not at all
A little
Moderately
Quite a bit
Extremely
Have you experienced increased appetite or cravings for food in the past week?
*
No change
Slight increase
Moderate increase
Significant increase
How would you describe your ability to focus or concentrate in the past week?
*
Very poor
Below average
Average
Above average
Excellent
Have you experienced physical discomfort (such as headaches or muscle aches) in the past week?
*
Not at all
Mild
Moderate
Severe
How strong have your urges or cravings for stimulants been in the past week?
*
None
1
2
3
4
5
6
7
8
9
Very strong
10
1 is None, 10 is Very strong
Please share any additional comments or experiences related to stimulant withdrawal symptoms.
Submit Questionnaire
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