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QUESTIONNAIRE

WHEN ANSWERING THESE QUESTIONS, PLEASE USE THE FOLLOWING SCALE:

1 - I don’t experience this or I experience this very infrequently
2 - I experience this to a small degree or very mildly
3 - I experience this about 2-3 times per week
4 - I experience this on a fairly regular basis
5 - I experience this daily or fairly severely

PAIN

I have back pain

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I have neck pain

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I have joint pain

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My pain limits my daily activities

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I have headaches

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I have muscle aches

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I suffer from overall body pain

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I have migraine headaches

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I experience physical pain on a daily basis

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I need to take ibuprofen or another pain reliever on a regular basis

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SLEEP

I have trouble sleeping soundly through the night

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I have difficulty falling asleep

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I wake up during the night and have trouble falling back to sleep

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I do not wake up feeling rested

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I often feel like I want to sleep more hours

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I have sleep apnea

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I sleep very lightly

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I suffer from chronic insomnia

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I take an over the counter sleep aid

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I take a prescription sleep aid

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Sleep more than 10-12 hours on some days

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ENERGY

I feel like I don't have as much energy as I would like

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I need coffee or tea to get going in the morning

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Low energy affects me on a daily basis

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I need energy drinks to sustain my energy

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I don't feel I have enough energy to exercise

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I feel good in the morning but my energy quickly dips

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I experience a low in energy around 3-5pm in the afternoon

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I get very tired after eating a meal

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I would like to have more energy during the day

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Having enough energy is an issue for me in my daily life

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I feel more energized after listening to my frequencies every day

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DIGESTION

My stomach is upset after a meal

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I experience bloating on a regular basis

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I take Tums or something similar on a regular basis

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I have heartburn

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5

My food does not seem to digest well

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I find myself burping after a meal

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I avoid fatty foods and do not tolerate them well

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5

Having regular bowel movements is not common for me

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My bowel movements tend to be loose

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I suffer from constipation

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5

I go to a hydro-colon therapist to clean my colon once a month

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5

WEIGHT, APPETITE, AND BLOOD SUGAR

I feel that I need to lose weight

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I crave sugary foods

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I crave fatty foods

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I have to eat many times during the day to keep my blood sugar stable

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5

I find it difficult to exercise on a regular basis

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No matter how little I eat, I cannot lose weight

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I find it hard to follow a healthy food plan

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I tend to eat well during the day, but eat unhealthy or excess in the evening

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I am good on a diet for a while and then fall off of it

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No matter how hard I try, I cannot lose the weight

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BRAIN AND FOCUS

I find it difficult to focus my attention on tasks I need to do

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My attention is easily lost to distractions

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I find that it hard to retain information after I read or watch it

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I would like to have more mental clarity

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I forget sometimes why I walked into a room or where the keys are

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I find that stimulants like coffee or energy drinks help me to focus

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My memory is not as sharp as I would like for it to be

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I find it hard to concentrate when I am trying to learn something new

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Feeling hopeless, loneliness and sad everyday

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Feeling better after listening to my frequencies

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Feeling motivated after a virtual QBF balancing session

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Experiencing brain fog in the morning

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Experiencing brain fog in the afternoon after 3pm

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MUSCLE FATIGUE AND STIFFNESS

Feeling whole body muscle fatigue in the morning

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Feeling whole body muscle stiff in the morning

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5

Feeling whole body muscle fatigue in the afternoon

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2

3

4

5

Feeling whole body muscle stiff in the afternoon

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2

3

4

5

Feeling upper body muscle fatigue in the morning

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2

3

4

5

Feeling lower body muscle fatigue in the morning

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2

3

4

5

Feeling upper body muscle fatigue in the afternoon

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2

3

4

5

Feeling lower body muscle fatigue in the afternoon

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2

3

4

5

Feeling upper body muscle stiff in the morning

1

2

3

4

5

Feeling lower body muscle stiff in the morning

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2

3

4

5

Feeling upper body muscle stiff in the afternoon

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2

3

4

5

Feeling lower body muscle stiff in the afternoon

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4

5

Can't sit more than 10 minutes due to muscle fatigue and weakness

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Can't walk more than 10 steps due to muscle fatigue and weakness

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I declare that the info I’ve provided is accurate & complete

CONTACT ME

4960 Higbee Ave. NW, Suite 102, Canton, Ohio 44718

quantumtransformationllc@gmail.com

(440) 975-6646

By Appointment Only

"Everything in life is vibration."

- Albert Einstein

QUESTIONNAIRE

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