Please respond to each item by marking one box per row.

In the past 7 days...

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* 1. Have you used our anti-anxiety formula β-Calmed?

In the last week...

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* 2. I felt fearful

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* 3. I found it hard to focus on anything other than my anxiety

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* 4. My worries overwhelmed me

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* 5. I felt uneasy

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* 6. I felt nervous

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* 7. I felt like I needed help for my anxiety

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* 8. I felt anxious

In the last week...

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* 9. I felt tense

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* 10. What is your date of birth?

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* 11. Contact Info

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* 12. Physician's Name

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