Pharmacy Information Patient's Name * First Name Last Name Date of Birth * MM DD YYYY Email * Mobile Phone * (###) ### #### Current Weight * Check all areas that you would like to improve * Energy Focus Motivation Memory Mood How many cups of coffee or caffeinated beverages do you typically drink in a day? * 0 1 2 3+ How do you feel when you consume caffeine? * Energized Focused Nervous No Effect How often do you exercise? * Never 1-2 times per week 3-4 times per week 4+ times per week Do you often consume 5 or more alcoholic drinks in a singleday? * Yes No Do you smoke cigarettes or vape nicotine? * Yes No How many hours do you typically sleep in a night? * Varies greatly 0-4 hours 4-6 hours 6-8 hours 8+ hours Do you typically feel rested when you wake up? * Never Rarely Sometimes Often Always How would you rate your energy in a typical day? * 1 (Exhausted) 2 3 4 5 6 7 8 9 10 (Energized) Do you have trouble getting out of bed in the morning? Never Rarely Sometimes Often Always Do you get distracted easily? Never Rarely Sometimes Often Always How often do you check social media? * Never Few times per day Often Very Often Can't stop How would you rate your overall productivity? * 1 (Unproductive) 2 3 4 5 6 7 8 9 10 (Very productive) Do you have trouble finishing things that you start? * Never Rarely Sometimes Often Always Do you procrastinate? * Never Rarely Sometimes Often Always How would you rate your overall mood? * 1 (Depressed) 2 3 4 5 6 7 8 9 10 (Ecstatic) Do you experience anxiety in social situations? * Never Rarely Sometimes Often Always Do you feel regret when thinking about the past? * Never Rarely Sometimes Often Always Do you feel worry when thinking about the future? * Never Rarely Sometimes Often Always Do you have difficulty remembering names? * Never Rarely Sometimes Often Always Do you forget things such as keys or umbrella? * Never Rarely Sometimes Often Always Thank you! Your information has been received. You will be contacted by our staff if we need additional information.
