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ASSESS THE WELLNESS OF YOUR MIND
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Page 1 of 4
1.
In general, how often do you, experience mood swings?
Rarely
Some times
Most of the time
2.
In general, how often do you, experience headache due to stress/tension?
Rarely
Some times
Most of the time
3.
In general, how often do you, feel anxious about future things?
Rarely
Some times
Most of the time
4.
In general, how often do you, get less than eight hours of sleep?
Rarely
Some times
Most of the time
5.
In general, how often do you, feel tired and exhausted?
Rarely
Some times
Most of the time
Page 2 of 4
6.
In general, how often do you, get sick or get infections?
Rarely
Some times
Most of the time
7.
In general, how often do you, have problems, such as bloating, acidity etc?
Rarely
Some times
Most of the time
8.
In general, how often do you, experience forgetfulness/poor memory?
Rarely
Some times
Most of the time
9.
In general, how often do you, feel dissatisfied due to incomplete evacuation of your bowels?
Rarely
Some times
Most of the time
10.
In general, how often do you, concern, about the bad choices in your food affects your overall health?
Rarely
Some times
Most of the time
Page 3 of 4
11.
Have you been feeling difficulty to concentrate on what you are doing?
Rarely
Some times
Most of the time
12.
Have you been feeling unhappy in your present situation?
Rarely
Some times
Most of the time
13.
Have you been feeling any decline in mental alertness/sharpness?
Rarely
Some times
Most of the time
14.
Have you been losing confidence in yourself?
Rarely
Some times
Most of the time
15.
Have you been getting angered easily?
Rarely
Some times
Most of the time
Page 4 of 4
16.
Have you been feeling sad or depressed?
Rarely
Some times
Most of the time
17.
Have you been feeling irritable due to the problems related to your gut?
Rarely
Some times
Most of the time
18.
Have you been feeling low energy in your daily activities OR waking up with brain fog?
Rarely
Some times
Most of the time
19.
Have you been feeling recurrent headaches or migraine attacks?
Rarely
Some times
Most of the time
20.
Have you been feeling any difficulty in learning new things?
Rarely
Some times
Most of the time
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