Name *Email Address *Mental Impact: Do you experience any of the following?Poor cognitive functionsTrouble concentratingPessimismDifficulty making decisionsPhysical Impact: Do you experience any of the following?FatigueSkin or nerve conditionsLowered immunityPoor sleepHeadachesUpset stomachMuscle tensionEmotional Impact: Do you experience any of the following?Mood swingsIncreased anxietyIncreased irritabilityEasily angeredDepressionIncreased impatienceIncreased nervousnessSpiritual Impact: How do you feel about God?DistantAngryForgottenIndifferentConfusedSubmit
