Follow - Up Survey | Youth MediMorphosis® - July 28, 2019 Please answer the questions below for the child who attended the July 2019 Youth MediMorphosis. This form must be filled out individually for each participating youth. Thank you! If you have any questions, please email customers@massajady.com . Question Title * 1. Youth's Full Name ... First Middle (if applicable) Last(This information will remain anonymous.) Question Title * 2. Youth's Birthday Month Day Year Age of child Date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Date Month menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date Day menu 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 Date Year menu In Utero (Mom is pregnant) Infant (under 12 months) 1 year old 2 years old 3 years old 4 years old 5 years old 6 years old 7 years old 8 years old 9 years old 10 years old 11 years old 12 years old 13 years old 14 years old 15 years old 16 years old 17 years old 18 years old Date Age of child menu Question Title * 3. Youth's Gender Female Male Displays transgender tendencies Prefer not to answer Question Title * 4. Parent/Guardian's Name ... First Last(This information will remain anonymous.) Question Title * 5. Parent/Guardian's Email Email Question Title * 6. How many times has the youth worked 1-on-1 with Mas Sajady including this Youth MediMorphosis event (phone or in-person)? 0 1-2 times 3-5 times 6 or more times Question Title * 7. Please rate how much the child is affected by any of the following AFTER the Youth MediMorphosis (please note that Youth MediMorphosis™ is not a medical program and does not provide treatment for these, or any, conditions): 1 - Very Low to None 2 - Low 3 - Medium 4 - High 5 - Extremely High ADD/ADHD ADD/ADHD 1 - Very Low to None ADD/ADHD 2 - Low ADD/ADHD 3 - Medium ADD/ADHD 4 - High ADD/ADHD 5 - Extremely High Anxiety Anxiety 1 - Very Low to None Anxiety 2 - Low Anxiety 3 - Medium Anxiety 4 - High Anxiety 5 - Extremely High Depression Depression 1 - Very Low to None Depression 2 - Low Depression 3 - Medium Depression 4 - High Depression 5 - Extremely High Anger Anger 1 - Very Low to None Anger 2 - Low Anger 3 - Medium Anger 4 - High Anger 5 - Extremely High Behavioral Challenges Behavioral Challenges 1 - Very Low to None Behavioral Challenges 2 - Low Behavioral Challenges 3 - Medium Behavioral Challenges 4 - High Behavioral Challenges 5 - Extremely High Learning Challenges Learning Challenges 1 - Very Low to None Learning Challenges 2 - Low Learning Challenges 3 - Medium Learning Challenges 4 - High Learning Challenges 5 - Extremely High Autism / On The Spectrum Autism / On The Spectrum 1 - Very Low to None Autism / On The Spectrum 2 - Low Autism / On The Spectrum 3 - Medium Autism / On The Spectrum 4 - High Autism / On The Spectrum 5 - Extremely High Question Title * 8. Based on observations of your child AFTER the Youth MediMorphosis event, please rate their level of achievement with the following: 1 - Very Low to None 2 - Low 3 - Medium 4 - High 5 - Extremely High Academics Academics 1 - Very Low to None Academics 2 - Low Academics 3 - Medium Academics 4 - High Academics 5 - Extremely High Identifying their Passions Identifying their Passions 1 - Very Low to None Identifying their Passions 2 - Low Identifying their Passions 3 - Medium Identifying their Passions 4 - High Identifying their Passions 5 - Extremely High Discovering their Natural Talents Discovering their Natural Talents 1 - Very Low to None Discovering their Natural Talents 2 - Low Discovering their Natural Talents 3 - Medium Discovering their Natural Talents 4 - High Discovering their Natural Talents 5 - Extremely High Expressing their Authentic Self Expressing their Authentic Self 1 - Very Low to None Expressing their Authentic Self 2 - Low Expressing their Authentic Self 3 - Medium Expressing their Authentic Self 4 - High Expressing their Authentic Self 5 - Extremely High Connecting with Others Connecting with Others 1 - Very Low to None Connecting with Others 2 - Low Connecting with Others 3 - Medium Connecting with Others 4 - High Connecting with Others 5 - Extremely High Emotional Intelligence Emotional Intelligence 1 - Very Low to None Emotional Intelligence 2 - Low Emotional Intelligence 3 - Medium Emotional Intelligence 4 - High Emotional Intelligence 5 - Extremely High Intuition Intuition 1 - Very Low to None Intuition 2 - Low Intuition 3 - Medium Intuition 4 - High Intuition 5 - Extremely High Physical Aptitude/Coordination Physical Aptitude/Coordination 1 - Very Low to None Physical Aptitude/Coordination 2 - Low Physical Aptitude/Coordination 3 - Medium Physical Aptitude/Coordination 4 - High Physical Aptitude/Coordination 5 - Extremely High Confidence/Self-Esteem/Self-Love Confidence/Self-Esteem/Self-Love 1 - Very Low to None Confidence/Self-Esteem/Self-Love 2 - Low Confidence/Self-Esteem/Self-Love 3 - Medium Confidence/Self-Esteem/Self-Love 4 - High Confidence/Self-Esteem/Self-Love 5 - Extremely High Question Title * 9. Based on the time following the Youth MediMorphosis Event, please rate how affected your child is for any applicable physical challenges (please note that Youth MediMorphosis™ is not a medical program and does not provide treatment for these, or any, conditions): 1 - Very Low to No Challenges 2 - Low 3 - Medium 4 - High 5 - Extremely High Challenges Digestion Digestion 1 - Very Low to No Challenges Digestion 2 - Low Digestion 3 - Medium Digestion 4 - High Digestion 5 - Extremely High Challenges Auto Immune Auto Immune 1 - Very Low to No Challenges Auto Immune 2 - Low Auto Immune 3 - Medium Auto Immune 4 - High Auto Immune 5 - Extremely High Challenges Cancer Cancer 1 - Very Low to No Challenges Cancer 2 - Low Cancer 3 - Medium Cancer 4 - High Cancer 5 - Extremely High Challenges Allergies Allergies 1 - Very Low to No Challenges Allergies 2 - Low Allergies 3 - Medium Allergies 4 - High Allergies 5 - Extremely High Challenges Blood Blood 1 - Very Low to No Challenges Blood 2 - Low Blood 3 - Medium Blood 4 - High Blood 5 - Extremely High Challenges Brain Injuries/Concussion Brain Injuries/Concussion 1 - Very Low to No Challenges Brain Injuries/Concussion 2 - Low Brain Injuries/Concussion 3 - Medium Brain Injuries/Concussion 4 - High Brain Injuries/Concussion 5 - Extremely High Challenges Bone and/or Growth Rate Bone and/or Growth Rate 1 - Very Low to No Challenges Bone and/or Growth Rate 2 - Low Bone and/or Growth Rate 3 - Medium Bone and/or Growth Rate 4 - High Bone and/or Growth Rate 5 - Extremely High Challenges Skin Skin 1 - Very Low to No Challenges Skin 2 - Low Skin 3 - Medium Skin 4 - High Skin 5 - Extremely High Challenges Asthma/Lung Asthma/Lung 1 - Very Low to No Challenges Asthma/Lung 2 - Low Asthma/Lung 3 - Medium Asthma/Lung 4 - High Asthma/Lung 5 - Extremely High Challenges Headaches Headaches 1 - Very Low to No Challenges Headaches 2 - Low Headaches 3 - Medium Headaches 4 - High Headaches 5 - Extremely High Challenges Heart Heart 1 - Very Low to No Challenges Heart 2 - Low Heart 3 - Medium Heart 4 - High Heart 5 - Extremely High Challenges Weight ( High or Low ) Weight ( High or Low ) 1 - Very Low to No Challenges Weight ( High or Low ) 2 - Low Weight ( High or Low ) 3 - Medium Weight ( High or Low ) 4 - High Weight ( High or Low ) 5 - Extremely High Challenges If other, please briefly specify: Question Title * 10. Testimonial Review: Have you or the youth noticed any shifts or changes since the event? How was your child's experience with the Youth MediMorphosis session with Mas? (If your child is old enough, they are welcome to respond to this question) Question Title * 11. The Testimonial Review may be shared publicly to help other families understand what's possible though elevating the consciousness of youth. If we use yours, how would you like it displayed? Anonymously First Name, Last Initial First Name, Last Initial, Age of Youth Question Title * 12. Today's Date: Date Date Submit
