Mind/Body Wellness Your First NameField is required!Field is required!Your Last NameField is required!Field is required!Phone NumberField is required!Field is required!Your E-mail AddressField is required!Field is required!The purpose of this questionnaire is to help understand the potential link between physical and emotional health. It serves to help the facilitator in determining what changes can be made to your diet and behavior to improve overall wellbeing.How would you rate your current physical health?GoodFairPoorField is required!Field is required!Are you currently experiencing overwhelming sadness, grief, or depression?YesNoField is required!Field is required!Over the past 2 weeks, how often have you been bothered by any of the following problems:Trouble falling asleep, staying asleep, or sleeping too much.Not at allSeveral daysMore than half daysNearly every dayField is required!Field is required!Feeling tired or having little energy.Not at allSeveral daysMore than half daysNearly every dayField is required!Field is required!Poor appetite or overeating.Not at allSeveral daysMore than half daysNearly every dayField is required!Field is required!Feeling bad about yourself or that you are a failure or have let yourself or your family down.Not at allSeveral daysMore than half daysNearly every dayField is required!Field is required!Trouble concentrating on things, such as reading the newspaper or watching tv.Not at allSeveral daysMore than half daysNearly every dayField is required!Field is required!Are you currently experiencing anxiety, panic attacks or have any phobias?YesNoField is required!Field is required!Are you currently taking any medication?YesNoField is required!Field is required!Are you currently experiencing any chronic pain?YesNoField is required!Field is required!- How do you prefer to communicate with Dr. David? -Live in Dubai or LebanonVia video sessions- How do you prefer to communicate with Dr. David? -Field is required!Field is required!Submit
