Please submit within 24-48 hours of your last session. This information is used to help optimize your treatment.
Name
*
First Name
Last Name
Date of last session
*
-
Month
-
Day
Year
Date Picker Icon
Slept better
*
Please Select
Yes
No
Not Applicable
More energy
*
Please Select
Yes
No
Not Applicable
Calm/Relaxed
*
Please Select
Yes
No
Not Applicable
Less hyper
*
Please Select
Yes
No
Not Applicable
Better concentration
*
Please Select
Yes
No
Not Applicable
Happier/Feeling up
*
Please Select
Yes
No
Not Applicable
Reduction of headache
*
Please Select
Yes
No
Not Applicable
Moving in slow motion
*
Please Select
Yes
No
Not Applicable
More alert/Awake
*
Please Select
Yes
No
Not Applicable
Feeling of well-being
*
Please Select
Yes
No
Not Applicable
Reduction of irritability
*
Please Select
Yes
No
Not Applicable
Felt physically better
*
Please Select
Yes
No
Not Applicable
Less motivated
*
Please Select
Yes
No
Not Applicable
More stable mood
*
Please Select
Yes
No
Not Applicable
Decreased obsession
*
Please Select
Yes
No
Not Applicable
Decreased pain
*
Please Select
Yes
No
Not Applicable
Less anxious
*
Please Select
Yes
No
Not Applicable
Less anxious
*
Please Select
Yes
No
Not Applicable
(H) Emotionally reactive
*
Please Select
Yes
No
(H) Agitated/Sped up
*
Please Select
Yes
No
(H) Physical tension/Muscle spasms
*
Please Select
Yes
No
(H) Physical tension/Muscle spasms
*
Please Select
Yes
No
(H) Heart palpitations
*
Please Select
Yes
No
(L) Sadness/Crying
*
Please Select
Yes
No
(L) Emotional sensitivity
*
Please Select
Yes
No
(L) Sedated/Slowed down
*
Please Select
Yes
No
(L) Dizziness
*
Please Select
Yes
No
(L) Silly mood
*
Please Select
Yes
No
(L) Difficulty walking
*
Please Select
Yes
No
(L) Heaviness
*
Please Select
Yes
No
Comments
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