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Cognitive & Emotional Questionnaire

Fill out the form below and click "Submit"
to send us your information for evaluation.

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Name*:

Email*:

Do you feel sad and/or grumpy?*:

Yes No

Do you have less interest in normal activities?*:

Yes No

Do you wake up repeatedly during the night?*:

Yes No

Do you have difficulty turning of your thoughts when you lay down to sleep?*:

Yes No

Do you feel tense and have trouble relaxing?*:

Yes No

Are you forgetful?*:

Yes No

Do you have difficulty concentrating?*:

Yes No

Do you have difficulty learning new things?*:

Yes No

Do you feel overly active and compelled to do things, like being driven by a motor?*:

Yes No

Do you have a short attention span?*:

Yes No

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