Location

3446 Mt. Diablo Blvd.
Lafayette, CA 94549

Store Hours

Mon – Fri 10:00 – 05:30
Sat. – 09:00 – 02:00

DIRECTIONS

This questionnaire asks you to assess how you have been feeling during the last four months. All information is held in strict confidence. Take all the time you need to complete this questionnaire.

For each question, choose the number that best describes your symptoms:

No or Rarely—You have never experienced the symptom or the symptom is familiar to you but you perceive it as insignificant (monthly or less)
Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger
Often—Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it
Frequently—Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis

Some questions require a YES or NO response.