Nervous System Reset Activation
Share your baseline observations for your care team. This form and the AI assistant provide information collection, general education and navigation only; they do not diagnose, treat, or create a treatment plan. For chest pain, severe breathing difficulty, or immediate danger, call 911 or local emergency services now rather than completing this form.
Unique ID
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Goals
What are your top 3 goals for participating in the program?
*
What does success look like for you upon completing this program?
Current State
Overall energy level
Low
0
1
2
3
4
5
6
7
8
9
High
10
0 is Low, 10 is High
Mood stability
Unstable
0
1
2
3
4
5
6
7
8
9
Stable
10
0 is Unstable, 10 is Stable
Mental clarity
Foggy
0
1
2
3
4
5
6
7
8
9
Clear
10
0 is Foggy, 10 is Clear
Physical tension
None
0
1
2
3
4
5
6
7
8
9
Severe
10
0 is None, 10 is Severe
Reported Physical and Emotional Experiences
Rapid Heartbeat
Never
Rarely
Sometimes
Often
Almost always
Sweating
Never
Rarely
Sometimes
Often
Almost always
Muscle tension
Never
Rarely
Sometimes
Often
Almost always
Irritability
Never
Rarely
Sometimes
Often
Almost always
Restlessness
Never
Rarely
Sometimes
Often
Almost always
Digestive issues
Never
Rarely
Sometimes
Often
Almost always
Difficulty concentrating
Never
Rarely
Sometimes
Often
Almost always
Experiences of Disconnection or Difficulty Moving
Which of these experiences have you noticed?
Feeling numb or disconnected
Difficulty moving
Sense of paralysis
Emotionally shut down
Other
Rest and Well-Being Experiences
Sense of calm
Never
Rarely
Sometimes
Often
Almost always
Deep relaxation
Never
Rarely
Sometimes
Often
Almost always
Restorative sleep
Never
Rarely
Sometimes
Often
Almost always
Positive mood
Never
Rarely
Sometimes
Often
Almost always
Ease in social situations
Never
Rarely
Sometimes
Often
Almost always
Sleep
How many hours do you typically sleep per night?
*
How would you rate your sleep quality?
Poor
0
1
2
3
4
5
6
7
8
9
Excellent
10
0 is Poor, 10 is Excellent
Do you have trouble falling or staying asleep?
Yes
No
Lifestyle
How often do you exercise per week?
What kinds of exercise do you regularly do?
Cardio
Strength training
Yoga/Pilates
Sports
Other
How would you describe your nutrition?
Very healthy
Moderately healthy
Needs improvement
Other
Stress Sources
Which of the following are significant sources of stress for you?
Work
Family
Finances
Health
Relationships
Other
Recovery Habits
Which recovery habits do you practice regularly?
Meditation
Breathwork
Stretching
Massage
Nature walks
Other
Medical History
Do you have any current or past medical conditions relevant to your wellness journey?
Please list any medications or supplements you are currently taking.
Wearables
Do you use any wearable health devices?
Yes
No
If yes, please list the devices and what metrics you track.
Final Notes and Consent
Any final notes or information you'd like to share?
Submit Assessment
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