Name
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Email
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Phone
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At night, what usually happens when you try to sleep?
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My mind keeps replaying thoughts, and my body feels restless
I feel emotionally or physically heavy without knowing exactly why
I feel tired, but my body doesn’t fully relax or switch off
I sleep easily and feel relaxed
How do you feel physically on most days?
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Low energy, frequent fatigue, and lack of motivation
Energy comes and goes, but I often feel drained
I manage daily tasks, but don’t feel truly active or fresh
I feel energetic and active most of the time
How clear are you about managing your health and well-being?
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I feel confused and don’t know the root cause of my issues
I rely mostly on medication without full understanding
I try different things, but don’t see consistent improvement
I clearly understand my body and how to manage it
How would you describe your overall state right now?
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Overwhelmed, low on energy, and mentally tired
Managing somehow, but feeling unstable inside
Improving slowly, but still not fully in control
Calm, stable, and in control of my mind and body
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