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Quantum Transformations Brain

QUESTIONNAIRE

The Questionnaire is ONLY for people who are interested in trying Quantum Biofeedback for 4-8 sessions. The percentage changes in each condition represent how much your condition has improved. Please do not fill out the questionnaire if you are not interested in trying this noninvasive modality for your better health.

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

1

2

3

4

5

I have neck pain

1

2

3

4

5

I have joint pain

1

2

3

4

5

My pain limits my daily activities

1

2

3

4

5

I have headaches

1

2

3

4

5

I have muscle aches

1

2

3

4

5

I suffer from overall body pain

1

2

3

4

5

I have migraine headaches

1

2

3

4

5

I experience physical pain on a daily basis

1

2

3

4

5

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

1

2

3

4

5

SLEEP

I have trouble sleeping soundly through the night

1

2

3

4

5

I have difficulty falling asleep

1

2

3

4

5

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

1

2

3

4

5

I do not wake up feeling rested

1

2

3

4

5

I often feel like I want to sleep more hours

1

2

3

4

5

I have sleep apnea

1

2

3

4

5

I sleep very lightly

1

2

3

4

5

I suffer from chronic insomnia

1

2

3

4

5

I take an over the counter sleep aid

1

2

3

4

5

I take a prescription sleep aid

1

2

3

4

5

Sleep more than 10-12 hours on some days

1

2

3

4

5

ENERGY

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

1

2

3

4

5

I need coffee or tea to get going in the morning

1

2

3

4

5

Low energy affects me on a daily basis

1

2

3

4

5

I need energy drinks to sustain my energy

1

2

3

4

5

I don't feel I have enough energy to exercise

1

2

3

4

5

I feel good in the morning but my energy quickly dips

1

2

3

4

5

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

1

2

3

4

5

I get very tired after eating a meal

1

2

3

4

5

I would like to have more energy during the day

1

2

3

4

5

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

1

2

3

4

5

I feel more energized after listening to my frequencies every day

1

2

3

4

5

DIGESTION

My stomach is upset after a meal

1

2

3

4

5

I experience bloating on a regular basis

1

2

3

4

5

I take Tums or something similar on a regular basis

1

2

3

4

5

I have heartburn

1

2

3

4

5

My food does not seem to digest well

1

2

3

4

5

I find myself burping after a meal

1

2

3

4

5

I avoid fatty foods and do not tolerate them well

1

2

3

4

5

Having regular bowel movements is not common for me

1

2

3

4

5

My bowel movements tend to be loose

1

2

3

4

5

I suffer from constipation

1

2

3

4

5

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

1

2

3

4

5

WEIGHT, APPETITE, AND BLOOD SUGAR

I feel that I need to lose weight

1

2

3

4

5

I crave sugary foods

1

2

3

4

5

I crave fatty foods

1

2

3

4

5

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

1

2

3

4

5

I find it difficult to exercise on a regular basis

1

2

3

4

5

No matter how little I eat, I cannot lose weight

1

2

3

4

5

I find it hard to follow a healthy food plan

1

2

3

4

5

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

1

2

3

4

5

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

1

2

3

4

5

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

1

2

3

4

5

BRAIN AND FOCUS

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

1

2

3

4

5

My attention is easily lost to distractions

1

2

3

4

5

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

1

2

3

4

5

I would like to have more mental clarity

1

2

3

4

5

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

1

2

3

4

5

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

1

2

3

4

5

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

1

2

3

4

5

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

1

2

3

4

5

Feeling hopeless, loneliness and sad everyday

1

2

3

4

5

Feeling better after listening to my frequencies

1

2

3

4

5

Feeling motivated after a virtual QBF balancing session

1

2

3

4

5

Experiencing brain fog in the morning

1

2

3

4

5

Experiencing brain fog in the afternoon after 3pm

1

2

3

4

5

MUSCLE FATIGUE AND STIFFNESS

Feeling whole body muscle fatigue in the morning

1

2

3

4

5

Feeling whole body muscle stiff in the morning

1

2

3

4

5

Feeling whole body muscle fatigue in the afternoon

1

2

3

4

5

Feeling whole body muscle stiff in the afternoon

1

2

3

4

5

Feeling upper body muscle fatigue in the morning

1

2

3

4

5

Feeling lower body muscle fatigue in the morning

1

2

3

4

5

Feeling upper body muscle fatigue in the afternoon

1

2

3

4

5

Feeling lower body muscle fatigue in the afternoon

1

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

1

2

3

4

5

Feeling upper body muscle stiff in the afternoon

1

2

3

4

5

Feeling lower body muscle stiff in the afternoon

1

2

3

4

5

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

1

2

3

4

5

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

1

2

3

4

5

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

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