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Study Participants: Evaluation Form
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Home
What We Do
Our Tech
Our Mission
Kitcore CBD
About Us
About You
Before & After
Testimonies
Deep Dive
The Science
Study Participants: Evaluation Form
Take Action
Contact Us
Deep Dive
The Science
Study Participants: Evaluation Form
Questionnaire
tell us about you
Name
*
First Name
Last Name
Email
*
Subject
*
Message
*
Date of Birth
*
MM
DD
YYYY
Height & Weight
Today's Date
*
MM
DD
YYYY
Please list any conditions you have been diagnosed with:
*
Do you have a history of injury, if so where?
Please rate pain & discomfort level to specific area of the body WHEN GOING TO BED:
Head & Neck
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Shoulders & Upper back
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Lower back
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Hips
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Knees
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Various joint pain
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Please describe any other chronic pain you are experiencing:
Please rate pain & discomfort level to specific area of the body WHEN YOU ARISE:
Head & Neck
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Shoulders & Upper back
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Lower back
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Hips
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Knees
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Various joint pain
*
No pain
Rare low
Low-grade continuos
Moderate
High-level pain
Extreme pain
Please describe any other chronic pain you are experiencing:
Energy & Stamina
Do you drink coffee or other caffeinated products for energy when you wake up or throughout the day?
*
Yes
No
Do you consume sugar to give you energy when you wake up or throughout the day?
*
Yes
No
Do you feel a drop in energy in the afternoon?
*
Yes
No
How would you rate your energy on the following sale, 1 being low, 10 being high.
*
1
2
3
4
5
6
7
8
9
10
Mental -Emotional
Do you feel grounded?
*
Yes
No
Are you currently experiencing:
Anxiety, If so on what scale (1-10)
1
2
3
4
5
6
7
8
9
10
Nervousness , If so on what scale (1-10)
1
2
3
4
5
6
7
8
9
10
Restlessness, If so on what scale (1-10)
1
2
3
4
5
6
7
8
9
10
Sleep disturbance If so on what scale (1-10)
1
2
3
4
5
6
7
8
9
10
Do you have panic attacks?
*
Yes
No
Do you experience night terrors?
*
Yes
No
Do you feel overwhelmed?
*
Yes
No
Cognitive
Do you have trouble focusing?
*
Yes
No
Do you have memory issues, if so is it short-term or long-term.
*
No memory issues
Short term memory issues
Long term memory issues
Do you have difficulties completing a task?
*
Yes
No
Do have brain fog, or lack mental clarity?
*
Yes
No
Sleep/Wake Patterns
What time do you go to sleep?
What time do you arise?
How many times do you wake during the night?
*
0
1
2
3
4
5
More than 5
Do you fall right back to sleep?
Yes
No
Do you lie awake for a while?
Yes
No
What wakes you up?
Urination
Pain
Anxiety
High Brain activity
Other
Do you frequently feel:
*
Hot
Cold
Fatigued
Night Sweats
Thank you!
