Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Symptom Severity & FrequencyFor each of the following, rate how much you have experienced this over the past 7 days on a scale from 0 (Not at all) to 10 (Extreme or Constant) 1. Overall Mood Selected Value: 0 2. Anxiety Level Selected Value: 0 3. Depressive Feelings (sadness, hopelessness) Selected Value: 0 4. Stress Reactivity (how easily stressed) Selected Value: 0 5. Daily Energy Levels Selected Value: 0 6. Sleep Quality (falling asleep, staying asleep) Selected Value: 0 7. Concentration/Attention Selected Value: 0 8. Memory and Recall Ability Selected Value: 0 9. Motivation to Engage in Tasks Selected Value: 0 10. Sense of Well-Being & Fulfillment Selected Value: 0 Functioning & Quality of LifeOver the past 7 days, how often did you experience the following? (0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Always) 11. Able to complete daily responsibilities (work/home life) Selected Value: 0 12. Able to enjoy social interactions Selected Value: 0 13. Ability to plan activities and follow through Selected Value: 0 14. Time spent feeling overwhelmed Selected Value: 0 15. Physical pain or discomfort affecting routine Selected Value: 0 Detailed Cognitive and Emotional ChangesPlease indicate how much you agree with these statements (0: Strongly Disagree – 10: Strongly Agree) 16. I feel more creative or able to think of novel ideas. Selected Value: 0 17. I notice increased emotional resilience during stressful moments. Selected Value: 0 18. I feel more connected to people around me. Selected Value: 0 19. My self-talk or inner dialogue feels more positive. Selected Value: 0 20. I notice any unexpected emotional reactions (positive or negative). Selected Value: 0 How & reactions Side Effects & Safety TrackingPlease indicate how often you experienced each in the past 7 days (0: Never, 1: Rarely, 2: Sometimes, 3: Often, 4: Always) 21. Nausea Selected Value: 0 22. Dizziness Selected Value: 0 23. Headaches Selected Value: 0 24. Heart palpitations or physical tension Selected Value: 0 25. Any perceptual changes (e.g., visual or sensory distortions) Selected Value: 0 Impact on Lifestyle and Habits26. Since starting the protocol, how has your exercise routine changed?ImprovedNo ChangeWorsened27. How has your sleep duration changed?IncreasedNo ChangeDecreased28. How has your diet or appetite changed? (Better | Worse | No Change)ImprovedNo ChangeWorsened29. How sustainable does your current microdosing schedule feel? (0 Very Unsustainable to 10 Very Sustainable) Selected Value: 0 30. Have you experienced any unexpected events or challenges since starting?Overall Self-Assessment31. Compared to before starting microdosing, how would you rate your overall health now?Much ImprovedSlightly ImprovedSameSlightly WorseMuch Worse32. What benefits, if any, have you experienced that weren’t captured above?33. What challenges remain for you that you hoped microdosing would help? Submit
