Digital Onboarding Symptom Survey V1

1
Please share your email address.* This field is required.
example@example.com
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Are you over 18?* This field is required.
YESNO
3
Are you under 13?
YESNO
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Curious to see how Freespira works?Learn more by watching this video or skip ahead if you'd like.
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Here are the benefits of using Freespira:

Easy to get started with 17-minute breathing sessions twice daily

The Freespira device is portable and can be used anywhere (e.g., at home, in the car, at the beach, etc.)

Treatment is 28 days but the relief is long-lasting

Access to a dedicated coach who will help you along the way
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Do you want to continue learning about Freespira or would you like to get started with treatment?
Continue LearningStart Treatment
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Curious to know what our device looks like?Once you're enrolled, you'll receive a kit. Each kit includes a breathing sensor that monitors your breathing during sessions. With this feedback, you'll be able to adjust your breathing patterns over 28 days to experience long-lasting relief.
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Did you know?

Freespira has helped more than 7,000 patients who have suffered from panic/anxiety attacks and PTSD symptoms. Unlike many treatments, Freespira is medication-free and is completed on your schedule. In a study, 9 out of 10 patients:

Were panic attack-free immediately after treatment

Experienced long-lasting symptom relief

Would recommend Freespira to a friend or family member
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What would you like Freespira to help you with?* This field is required.
Panic or anxiety attacks
PTSD (trauma) symptoms
Panic attack and PTSD symptoms
Not sure
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Hear how Freespira changed Olivia's life.
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Hear how Freespira changed Sarah's life.
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Are you ready to begin treatment?* This field is required.
YesI have more questions.
13
When did your doctor first diagnose you with PTSD?* This field is required.
14
What is the name on your insurance card?* This field is required.
First Name
Last Name
15
Do you have a preferred name?
16
How did you hear about Freespira?* This field is required.
Please Select
Please Select
Case Manager
Clinician/Provider
Community Event
Direct Mailer
Email
Facebook/Instagram Ads
Google Ads
Google Search
News Media
Newsletter
Other
Phone Call
SMS Message
Social Media
Word of Mouth
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What is your phone number?* This field is required.
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Do you have other questions you would like us to answer?Let us know how you would prefer us to follow up on your question (e.g., email, text, phone call).
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Large
Normal
Small
Ok
Ok
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Who is your insurance provider?* This field is required.We will check your insurance and help us get you started
Chorus Community Health Plans (CCHP)
Comcast
Highmark BCBS of Pennslyvania, West Virginia, Delaware or New York
Security Health Plan (SHP)
TRICARE
I am a Veteran with current VA benefits
Aetna
Cigna
Elevance Health Inc. (formerly Anthem)
Humana
Kaiser Permanente
UnitedHealthcare
Other
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What is your member ID number on your insurance card?This helps us verify your insurance and get you started
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What is your birthdate?* This field is required.We use this to help verify your insurance is active.
Date
Month
Day
Year
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Based on your insurance selection, it looks like Freespira is not a covered benefit.

However, you can still get started with Freespira. You can file a claim with your insurance, use your FSA or HSA funds, or you can take advantage of our flexible payment plans. The cost of treatment is $2,000.
23
Are you ready to start your Freespira treatment?
Yes
No
I'm not sure. I would like to speak to a member of your care team after finishing this form.
I'm not sure. I would like to learn more.
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Can you share why you're not interested in treatment at this time?Your answer will help us improve the journey for others.
Huge
Large
Normal
Small
Ok
Ok
25
How do you self-identify?* This field is required.
Male
Female
Non-Binary
Other
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Is there any chance you are pregnant right now? * This field is required.
YESNO
27
Have you been diagnosed with COPD or emphysema?* This field is required.
Yes
No
28
Have you had COVID or any other respiratory condition in the last month?
YESNO
29
Have you had seizures?
YESNO
30
Have you ever been diagnosed with bipolar disorder, psychosis, or delusional disorder?* This field is required.
YESNO
31
Which disorder* This field is required.
Please Select
Please Select
Bipolar Disorder
Psychosis
Delusional Disorder
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Do you have a history of suicide attempts or suicidal thoughts?* This field is required.
YESNO
33
Are you currently feeling suicidal or have thoughts of suicide?* This field is required.
YESNO
34
If you’re ever struggling or need crisis support, you can call or text 988 for the National Crisis and Support Lifeline. The Lifeline is available 24/7.
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Your safety is our top priority. We recommend you pause this survey and ask you to call or text 988, the Suicide and Crisis Lifeline. The Lifelife offers free, private support 24/7. For other types of emergencies, call 911.
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Are you planning to take any vacations or extended time away from home during your treatment?* This field is required.
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Can you commit to doing two 17-minute breathing sessions each day for 28 days?* This field is required.
YESNO
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What could make it difficult to complete two treatment sessions a day?
39
Several of the following questions refer to panic attacks and limited-symptom attacks. For this questionnaire we define a panic attack as a sudden rush of fear or discomfort accompanied by at least 4 of the symptoms listed below. In order to qualify as a sudden rush, the symptoms must peak within 10 minutes. Episodes like panic attacks but having fewer than 4 of the listed symptoms are called limited-symptom attacks.
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Do you experience panic attacks?* This field is required.
YESNO
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Please select all the symptoms you experience.* This field is required.
Rapid or pounding heartbeat
Chest pain or discomfort
Chills or hot flushes
Sweating
Nausea
Fear of losing control or going crazy
Trembling or shaking
Dizziness or faintness
Breathlessness
Feeling of unreality
Fear of dying
Feeling of choking
Numbness or tingling
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How many panic attacks or limited-symptom attacks did you have during the past month ?* This field is required.
No panic or limited-symptom attacks
Mild: No full panic attacks and no more than 1 limited-symptom attack per day
Moderate: 1or 2 full panic attacks and/or multiple limited-symptom attacks per day
Severe: More than 2 full attacks but not more than per day on average
Extreme: Full panic attacks occurred more than once a day, more days than not
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In the past month, how distressing were the attacks you had on average?* This field is required.
Not at all distressing, or no panic or limited-symptom attacks during the past month
Mild: Distressing (not too intense)
Moderate: Distressing (intense,but still manageable)
Severe: Distressing (very intense)
Extreme: Distressing (extreme distress during all attacks)
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In the past month, how often did you feel anxious or worried about your next panic attack?* This field is required.
Not at all
Occasionally or only mildly
Frequently or moderately
Very often or to a very disturbing degree
Nearly constantly and to a disabling extent
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Some people avoid places or situations where they fear having a panic attack. In the past month, how often did you feel afraid or avoid things because of panic attacks?* This field is required.
No fear or avoidance
Mild: Occasional fear and/or avoidance but I could usuallyconfront or endurethe situation. There was little or no modification of my lifestyle due to this.
Moderate: Noticeable fear and/or avoidance but still manageable. Iavoided some situations, but I could confront them with a companion. There was some modification of my lifestyle because of this, but my overall functioning was not impaired.
Severe: Extensive avoidance. Substantial modification of mylifestyle was required to accommodate the avoidance. making it difficult to manage usualactivities.
Extreme: Pervasive disabling fear and/or avoidance. Extensive modification in my lifestyle was required such that important tasks were not performed.
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Some people fear doing certain things because the physical feelings remind them of a panic attack. Or they may fear causing an attack. It can be exercise, sex, or bathing. Or it can be drinking coffee or watching a scary movie. In the past month, how often did you feel afraid or avoid activities like this?* This field is required.
No fear or avoidance of situations or activities becauseof distressing physical sensations
Mild: Occasional fear and/or avoidance, but usually I could confront or endure with little distress activities that cause physical sensations. There was little modification of my lifestyle due to this.
Moderate: Noticeable avoidance but still manageable. There was definite, but limited, modification of my lifestyle such that my overall functioning was not impaired.
Severe: Extensive avoidance. There was substantial modification of my lifestyle or interference in my functioning.
Extreme: Pervasive and disabling avoidance. There was extensive modification in my lifestyle due to this such that important tasks or activities were not performed.
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Some people fear doing certain things because of the physical sensations they cause. It may remind them of a panic attack. Or they may fear bringing on an attack. It can be exercise, bathing, drinking coffee, or watching a scary movie. In the past month, how often did you feel afraid or avoid activities like this?* This field is required.
No interference with work or home responsibilities
Slight interference with work or home responsibilities, but I could do nearly everything I could if I didn’t have these problems.
Significant interference with work or home responsibilities, but I still could manage to do the things I need to do.
Substantial impairment in work home responsibilities; there were many important things I couldn’t do because of these problems.
Extreme, incapacitating impairment, such that I was essentially unableto manage any work or home responsibilities.
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Panic attacks and limited symptom attacks can make it hard to live your life. So can fear and avoidance caused by panic attacks. Think about the past month. How much did these things get in the way of your ability to work or handle responsibilities at home?* This field is required.
No interference
Slight interference with social activities, but I could do nearly everything I could if I didn’t have these problems.
Significant interference with social activities, but I could manage to do most things if I made the effort.
Substantial impairment in social activities; there were many social thingsI couldn’t do because of these problems.
Extreme, incapacitating impairment, such that there was hardly anything social I could do.
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Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you havebbeen bothered by that problem in the past month.
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In the past month, how much were you bothered by the following?* This field is required.
Not at all
A little bit
Moderate
Quite a bit
Extreme
Repeated, disturbing, and unwanted memories of the stressful experience?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Repeated, disturbing dreams of the stressful experience?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Feeling very upset when something reminded you of the stressful experience?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Avoiding memories, thoughts, or feelings related to the stressful experience?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Trouble remembering important parts of the stressful experience?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Blaming yourself or someone else for the stressful experience or what happened after it?
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Having strong negative feelings such as fear, horror, anger, guilt, or shame?
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Loss of interest in activities that you used to enjoy?
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Feeling distant or cut off from other people?
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Irritable behavior, angry outbursts, or acting aggressively?
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
Taking too many risks or doing things that could cause you harm?
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Row 15, Column 4
Being 'super-alert' or watchful or on guard?
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Row 16, Column 4
Feeling jumpy or easily startled?
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Row 17, Column 4
Having difficulty concentrating?
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Row 18, Column 4
Trouble falling or staying asleep?
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Row 19, Column 4
Repeated, disturbing, and unwanted memories of the stressful experience?
Repeated, disturbing dreams of the stressful experience?
Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
Feeling very upset when something reminded you of the stressful experience?
Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
Avoiding memories, thoughts, or feelings related to the stressful experience?
Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
Trouble remembering important parts of the stressful experience?
Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
Blaming yourself or someone else for the stressful experience or what happened after it?
Having strong negative feelings such as fear, horror, anger, guilt, or shame?
Loss of interest in activities that you used to enjoy?
Feeling distant or cut off from other people?
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
Irritable behavior, angry outbursts, or acting aggressively?
Taking too many risks or doing things that could cause you harm?
Being 'super-alert' or watchful or on guard?
Feeling jumpy or easily startled?
Having difficulty concentrating?
Trouble falling or staying asleep?
Not at all
Row 0, Column 0
A little bit
Row 0, Column 1
Moderate
Row 0, Column 2
Quite a bit
Row 0, Column 3
Extreme
Row 0, Column 4
Not at all
Row 1, Column 0
A little bit
Row 1, Column 1
Moderate
Row 1, Column 2
Quite a bit
Row 1, Column 3
Extreme
Row 1, Column 4
Not at all
Row 2, Column 0
A little bit
Row 2, Column 1
Moderate
Row 2, Column 2
Quite a bit
Row 2, Column 3
Extreme
Row 2, Column 4
Not at all
Row 3, Column 0
A little bit
Row 3, Column 1
Moderate
Row 3, Column 2
Quite a bit
Row 3, Column 3
Extreme
Row 3, Column 4
Not at all
Row 4, Column 0
A little bit
Row 4, Column 1
Moderate
Row 4, Column 2
Quite a bit
Row 4, Column 3
Extreme
Row 4, Column 4
Not at all
Row 5, Column 0
A little bit
Row 5, Column 1
Moderate
Row 5, Column 2
Quite a bit
Row 5, Column 3
Extreme
Row 5, Column 4
Not at all
Row 6, Column 0
A little bit
Row 6, Column 1
Moderate
Row 6, Column 2
Quite a bit
Row 6, Column 3
Extreme
Row 6, Column 4
Not at all
Row 7, Column 0
A little bit
Row 7, Column 1
Moderate
Row 7, Column 2
Quite a bit
Row 7, Column 3
Extreme
Row 7, Column 4
Not at all
Row 8, Column 0
A little bit
Row 8, Column 1
Moderate
Row 8, Column 2
Quite a bit
Row 8, Column 3
Extreme
Row 8, Column 4
Not at all
Row 9, Column 0
A little bit
Row 9, Column 1
Moderate
Row 9, Column 2
Quite a bit
Row 9, Column 3
Extreme
Row 9, Column 4
Not at all
Row 10, Column 0
A little bit
Row 10, Column 1
Moderate
Row 10, Column 2
Quite a bit
Row 10, Column 3
Extreme
Row 10, Column 4
Not at all
Row 11, Column 0
A little bit
Row 11, Column 1
Moderate
Row 11, Column 2
Quite a bit
Row 11, Column 3
Extreme
Row 11, Column 4
Not at all
Row 12, Column 0
A little bit
Row 12, Column 1
Moderate
Row 12, Column 2
Quite a bit
Row 12, Column 3
Extreme
Row 12, Column 4
Not at all
Row 13, Column 0
A little bit
Row 13, Column 1
Moderate
Row 13, Column 2
Quite a bit
Row 13, Column 3
Extreme
Row 13, Column 4
Not at all
Row 14, Column 0
A little bit
Row 14, Column 1
Moderate
Row 14, Column 2
Quite a bit
Row 14, Column 3
Extreme
Row 14, Column 4
Not at all
Row 15, Column 0
A little bit
Row 15, Column 1
Moderate
Row 15, Column 2
Quite a bit
Row 15, Column 3
Extreme
Row 15, Column 4
Not at all
Row 16, Column 0
A little bit
Row 16, Column 1
Moderate
Row 16, Column 2
Quite a bit
Row 16, Column 3
Extreme
Row 16, Column 4
Not at all
Row 17, Column 0
A little bit
Row 17, Column 1
Moderate
Row 17, Column 2
Quite a bit
Row 17, Column 3
Extreme
Row 17, Column 4
Not at all
Row 18, Column 0
A little bit
Row 18, Column 1
Moderate
Row 18, Column 2
Quite a bit
Row 18, Column 3
Extreme
Row 18, Column 4
Not at all
Row 19, Column 0
A little bit
Row 19, Column 1
Moderate
Row 19, Column 2
Quite a bit
Row 19, Column 3
Extreme
Row 19, Column 4
1 of 20
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How would you like to schedule your initial appointment? You can select more than one option.* This field is required.
Receive a phone call
Receive a link via email
Receive a text/SMS message
52
We will review your information and get back to you. How would you like to be contacted?* This field is required.Select all that apply
Phone call
Email
Text message/SMS
53
What state do you live in?
54
On weekdays, what is the best time to connect with you?Please include timezone
55
We're sorry, but you are ineligible for Freespira treatment at this time. Freespira is available to individuals 18 and older. Please click Next to exit the survey.
56
PTSD Diagnosed
TRUEFALSE
57
Is Pregnant
TRUEFALSE
58
Not Pregnant
TRUEFALSE
59
Yes to disorder
TRUEFALSE
60
no to disorder
TRUEFALSE
61
Delusional Disorder
TRUEFALSE
62
Bipolar
TRUEFALSE
63
Psychosis
TRUEFALSE
64
Never suicidal
TRUEFALSE
65
yes to suicidal thoughts before
TRUEFALSE
66
not currently suicidal
TRUEFALSE
67
is currently suicidal
TRUEFALSE
68
pdss symptoms
PDSS_S01
PDSS_S02
PDSS_S03
PDSS_S04
PDSS_S05
PDSS_S06
PDSS_S07
PDSS_S08
PDSS_S09
PDSS_S10
PDSS_S11
PDSS_S12
PDSS_S13
69
symptom count #
70
PDSS Q1
71
PDSS Q2
72
PDSS Q3
73
PDSS Q4
74
PDSS Q5
75
PDSS Q6
76
PDSS Q7
77
PDSS total score
78
q1pcl5sf
79
q2pcl5sf
80
q3pcl5sf
81
q4pcl5sf
82
q5pcl5sf
83
q6pcl5sf
84
q7pcl5sf
85
q8pcl5sf
86
q9pcl5sf
87
q10pcl5sf
88
q11pcl5sf
89
q12pcl5sf
90
q13pcl5sf
91
q14pcl5sf
92
q15pcl5sf
93
q16pcl5sf
94
q17pcl5sf
95
q18pcl5sf
96
q19pcl5sf
97
q20pcl5sf
98
total pcl5 score
99
PANIC ATTACKS YES OR NO
TRUEFALSE
100
pcl5 above threshold
TRUEFALSE
101
pdss above threshold
TRUEFALSE
102
over18
TRUEFALSE
103
bipolar,dd,spy yes no
Please Select
Please Select
Yes
No
104
covid recently
Please Select
Please Select
Yes
No
105
preferred method
Please Select
Please Select
Phone
Text
Email
106
disease state
PTSD
Please Select
Panic
PTSD
107
status
yes
unsure
no
Type option 4
108
DO answer to tx
109
utm source
110
utm campaign172
111
utm content
112
utm term
113
results
Green
Age issue
Medical clearance needed
Assessor review score
Assessor review disorder
114
UTM Campaign
115
do you have a disorder
No
Please Select
Yes
No
I'm not sure
116
117
lead type
Hot
Warm
Should be Empty: