The information you complete will be kept confidential and will only be viewed by a select few Limitless Employees who are under a confidentiality agreement. If you feel uncomfortable sharing any of the below info, please skip the question and answer as many as you are comfortable with.

General Information

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* 1. General Information

Do you experience any of the following:

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* 2. Do you experience any of the following:

  Never Seldom Sometimes Often Always
Stress
Anxiety
Anxiousness
Inability to sleep
Inability to fully relax
Racing thoughts
unsubstantiated fear
Excessive fear
Tension and muscle stiffness
Do you experience any of the following:

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* 3. Do you experience any of the following:

  Never Seldom Sometimes Often Always
Excessive sadness
Depression
Suicidal thoughts
Negative attitude towards many things
Thoughts that life has passed you by
Detached from family and social networks
Do you experience any of the following:

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* 4. Do you experience any of the following:

  Never Seldom Sometimes Often Always
Forgetfulness
Scatter-brained
Lack of focus
Unable to remember numbers or instructions
Forget people's names
Write one thing in your life that you would like to change in the next 30 days (less than 30 words please)

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* 5. Write one thing in your life that you would like to change in the next 30 days (less than 30 words please)

Are you willing to commit to using the products and Breakthrough techniques as directed for at least 30 days?

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* 6. Are you willing to commit to using the products and Breakthrough techniques as directed for at least 30 days?

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