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Quality Of Life Questionnaire

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This questionnaire will help us to learn more about the age related symptoms of hormone deficiency and decline you may be experiencing.

Contact Time

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I Am At Least 30 Years Old, And My Age Is

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Your Gender (Choose One) Male Female (*Required)

Q1) I Have to struggle to finish task Yes No (*Required)	Q2) I feel a strong need to sleep during the day Yes No (*Required)	Q3) I often feel lonely even when I am with other people Yes No (*Required)
Q4) I have to read things several times before they sink in Yes No (*Required)	Q5) It is difficult for me to make friends Yes No (*Required)	Q6) It takes a lot of effort for me to do simple task Yes No (*Required)

Q7) I have a difficult time controlling my emotions Yes No (*Required)	Q8) I often lose track of what I want to say Yes No (*Required)	Q9) I lack confidence Yes No (*Required)
Q10) I have to push myself to do things Yes No (*Required)	Q11) I feel as if i let people down Yes No (*Required)	Q12) I find it hard to mix with people Yes No (*Required)

Q13) I feel worn out even when I have done nothing Yes No (*Required)	Q14) There are times when I feel very depressed Yes No (*Required)	Q15) I avoid responsibility when possible Yes No (*Required)
Q16) I feel as if i am a burden to people Yes No (*Required)	Q17) I often forget what people have said to me Yes No (*Required)	Q18) I find it difficult to plan ahead Yes No (*Required)

Q19) I am easily irritated by other people Yes No (*Required)	Q20) I often feel too tired to do the things I ought to do Yes No (*Required)	Q21) I have to force myself to do all of the things that need doing Yes No (*Required)
Q22) I often have to force myself to stay awake Yes No (*Required)	Q23) My memory lets me down Yes No (*Required)

Comments

Please explain any 'yes' answer to question on left

Please list any medications you are taking or allergic to

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Conscious Evolution Institute of Physicians Rejuvenation, 5608 PGA Boulevard #208, Palm Beach Gardens, FL 33418.