Assessment Quiz

This assessment is designed to understand your current mental and emotional state.
Each question provides simple answer choices. Please select the option that best describes how you feel right now.

Your dosing overview will be shown below.

Name

First

Last

Email

Phone

Profile

Age Range (Required)

Sex (Required)

Male
Female
Prefer not to say

Height Range (Required)

5'0" or less
5'1"–5'5"
5'6"–5'10"
5'11" or taller

Quality Email Activity

Weight Range (Required)

Relationship Status (Required)

Single
Married
Partnered
Other

Mental & Emotional State

Primary Area of Difficulty (Select all that apply)

Emotional Sensitivity (Required)

Mental Stability (Required)

Mood Changes (Required)

Medications & Substances

Current Prescription Medications (Select all that apply)

Alcohol Use (Required)

None
Occasional
Moderate
Heavy

Smoking Status (Required)

Non smoker
Former smoker
Current smoker

Daily Foundations

Sleep Duration (Required)

Under 6 hours
6–7 hours
7–8 hours
8+ hours

Physical Activity Level (Required)

Inactive
Light activity
Moderate activity
Regular exercise

Diet Quality (Required)

Poor
Fair
Good
Excellent

Hydration (Required)

Poor
Fair
Good
Excellent

Self-Rated Mental Balance

Overall Mental & Emotional State (Required)

Experience Intensity Preference

Select what best matches your comfort level.

Notes

This assessment is designed to understand your current mental and emotional state. Each question provides simple answer choices. Please select the option that best describes how you feel right now.