VITALITY SURVEy

HOW OFTEN DO YOU: (score: never-0, seldom-1, occasionally-2, often-3, very often-4)

VITALITY SURVEY

First Name

Last Name

1. Experience indifference (don’t care)?

2. Lose your sense of humor/take life too seriously

3. Experience doubt or indecision?

4. Experience worry and anxiety?

5. Feel over cautious or pessimistic?

6. Lack self confidence or feel low self esteem?

7. Experience stress or feel nervous or tense?

8. Feel irritable or oversensitive?

9. Experience difficulty concentrating and loss of clear thought?

10. Experience inadequate energy (fatigue)?

11. Have coffee, tea, tobacco, sugar or other stimulants as a pick up?

12. Experience nervous indigestion?

13. Experience loss of sex drive?

14. Experience difficulty sleeping?

15. Experience difficulty getting up in the morning?

16. Feel run down?

17. Feel depressed?

18. Feel like crying for no reason?

19. Find it difficult to sit quietly (without fidgeting, talking, reading, watching TV, etc.)?

20. Find it difficult to express your feelings?

21. Experience rapid heart beat or panic?

22. Feel moody?

23. Feel suicidal or wonder whether life is worth living?

24. Have anxiety about not having enough money?

25. Fear ill health?

26. Fear criticism?

27. Fear loss of love?

28. Fear old age or death?

29. Feel “something is the matter with me” but don’t know what?

30. Think you might be going crazy (losing it)?

0 – 30 POINTS = Powerful Nerve Force -- HIGH VITALITY

31.40 POINTS = Strong Nerve Force -- GOOD VITALITY

41.50 POINTS = Moderate Nerve Force -- AVERAGE VITALITY

51.60 POINTS = Low Nerve Force -- LOW VITALITY

61.70 POINTS = Nervous Fatigue – NERVOUS FATIGUE

71.80 POINTS = Nervous Depletion – NERVOUS EXHAUSTION

81+ POINTS = Serious Nervous Exhaustion – SEVERE BURNOUT

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We will get back to you as soon as possible.

CONTACT INFORMATION

(732) 219-8699

46 Newman Springs Road East, Red Bank NJ 07701

info@LotusHealthAesthetics.com

*The minimum spend to use Care Credit is $1,000. No discounts can be applied when using Care Credit.

BUSINESS HOURS

Monday 10:00 AM - 3:00PM

Tuesday 9:00 AM - 7:00PM

Wednesday 9:00 AM - 8:00PM

Thursday 10:00 AM - 8:00PM

Friday 10:00 AM - 6:00PM

Saturday 10:00 AM - 4:00PM

Sunday Closed

Earlier or Later Times Available By Appointment

VITALITY SURVEy

VITALITY SURVEY

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