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Please complete all 7 steps of the form. You must click the green "Save Client Report" button on the bottom of Step 7 to complete the process.

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Multipage

Step 1 of 7 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.
Uncheck the trainer name to remove from Client Report. Having a Trainer on a client report gives the trainer access to the client report.
Date of Birth *
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Step 2 of 7 Personal Information

Medications
How many of these medications do you take daily?
Conditions
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Step 3 of 7 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 7 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 7 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 7 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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Step 7 of 7 Optional - Adverse Childhood Experiences Scale (ACES)

The Adverse Childhood Experience (ACE) Questionnaire is a 10-item self-report measure developed for the ACE study to identify childhood experiences of abuse and neglect. The study posits that childhood trauma and stress early in life, apart from potentially impairing social, emotional, and cognitive development, indicates a higher risk of developing health problems in adulthood.

Prior to your 18th birthday:

Vertical Tabs

Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
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