This subjective questionnaire is will give your health care practitioner a quick summary of symptoms or signs that may be related to health. It is not a substitute for professional medical advice from your health care provider. Do you frequently feel overwhelmed?*YesNoDo you often feel "tired and wired"?*YesNoDo you frequently feel drained?*YesNoDo you have less energy than normal? *YesNoDo you sometimes feel unhappy?*YesNoDo you occasionally have trouble sleeping at night?*YesNoDo you have difficulty in concentrating?*YesNoAre you angered easily? *YesNoDo you often rely on caffeine or nicotine to get through the day?*YesNoDo you use medication (or alcohol) to cope with your stressful lifestyle? *YesNoName* First Last Phone*Email*