Cognitive & Emotional Health Questionnaire

Do you feel sad and/or grumpy? *

Do you have less interest in normal activities?*

Do you wake up repeatedly during the night?*

Do you have difficulty turning off your thoughts when you lay down to sleep? *

Do you feel tense and have trouble relaxing? *

Are you forgetful?*

Do you have difficulty concentrating? *

Do you have difficulty learning new things?*

Do you feel overly active and compelled to do things, like being driven by a motor?*

Do you have a short attention span? *

Name*

First
Last

Email*