Page 2 of Questionnaire

Your job, occupation, service, etc:

Average stress level

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2

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4

5

Please share about any stressful aspects of your life:

Please describe your support systems/resources:

HEALTH HISTORY

Are you currently under the care of a medical doctor?

If yes, please provide the reason including specific details, as there are contraindications with BBTRS that we will discuss.

Are you currently taking any medication?

If yes, please provide more information: