Pre-Session Well-being Questionnaire

Pre-Session Well-being Questionnaire
- Complete this quick form to get a personalized snapshot of your current well-being.
- Please rate how you feel right now using the 0-5 scale, with 0 being the most negative and 5 the most positive.
- If you're using a phone, turning it sideways may help with visualization.
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Email
example@example.com
Sex

Other
Where are you completing this session and questionnaire?
1. How would you rate your current state of mind (emotional state)?

0

1

2

3

4

5

0 is very negative emotional state, 5 is very positive emotional state
2. How free from anxiety do you feel right now?

0

1

2

3

4

5

0 is not at all, 5 is completely free from anxiety
3. How free from stress do you feel right now?

0

1

2

3

4

5

0 is not at all, 5 is completely free from stress
4. How relaxed do you feel at this moment?

0

1

2

3

4

5

0 is not relaxed at all, 5 is completely relaxed
5. How would you rate your level of mental clarity right now?

0

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2

3

4

5

0 is completely foggy, 5 is perfectly clear
6. How free from fatigue do you feel right now?

0

1

2

3

4

5

0 is completely fatigued, 5 is not fatigued at all
7. How would you rate your energy level right now?

0

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2

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4

5

0 is completely drained, 5 is fully energyzed
8. How free from aches and pains do you feel right now?

0

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3

4

5

0 is not at all, 5 is completely free from pain
9. How would you rate your current level of physical comfort?

0

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2

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5

0 is feeling significant physical discomfort, 5 is feeling complete physical comfort
10. How would you rate your overall sense of well-being at this moment?

0

1

2

3

4

5

0 is poor overall well-being, 5 is excellent overall well-being
Your total wellness score before the session is:
By submitting this questionnaire, you consent to the use of your anonymous responses for research purposes to help evaluate the effects of NanoVi. Your data will remain confidential and will be used only in an aggregated form.
Should be Empty: