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Create Client Report

Please complete all 6 steps of the form. You must click the blue "Save Client Report" button on the bottom of Step 6 to complete the process.

Multipage

Step 1 of 6 Trainee Information

If you provide an email address, we will set up an account for you (if one does not exist) and email you a copy of your report. In some cases, an email is required.
Date of Birth *
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Step 2 of 6 Personal Information

Medications
How many of these medications do you take daily?
Conditions
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Step 3 of 6 Physical

Things I would like to change
Autonomic
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Sleep
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
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Step 4 of 6 Social

Things I would like to change
Social
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
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Step 5 of 6 Issues related to mood

Stress
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Anxiety
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Depression
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Anger
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Fear
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
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Step 6 of 6 Issues related to cognition

Attention
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Self-Control
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Creativity
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Learning
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Memory
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue
Thinking
In areas that are problems, please rate how much of a problem they are for you, from 0-5
0=Not an issue, 1=Minor issue, 5=Major issue

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