PHASE 1 WELLNESS QUESTIONNAIRE

Question 1: Do you remember your physicality being any different than it is currently? If so, in which way?

Question 2: Do you have any memories of food or drug allergies?

Question 3: Please describe your remembered sexual activity using one of the following words: abstinent, intermittent, promiscuous, or morbidly promiscuous.

Question 4: Do you have any memories of substance dependency? Which substances?

Question 5: Since your birthday, have you experienced any of the following? If so, how often and for how long?

A) Headaches, dizziness, or nausea
B) Confusion, anger, or sadness
C) Bleeding from the eyes, ears, or mouth
D) Phantom pains