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.

* 1. General Information

* 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

* 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

* 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

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

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

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