Thank you for participating in this 1 - minute survey! This provides us with valuable information which can be used to determine how much our programs are helping people.

We'll ask you to spend another minute filling this out again at the end of the program, and ask you for a follow-up afterwards.

With thanks,

Dawson Church, PhD
National Institute for Integrative Healthcare

Question Title

* 1. Event name:

Question Title

* 2. Your Initials:

Question Title

* 3. Your Age:

Question Title

* 4. Your gender:

Question Title

* 5. Highest level of education:

Question Title

* 6. What is your Email Address (will be used only for follow-up):

Question Title

* 7. Your phone number (will be used only if we can't reach you for follow-up via email):

(Questions 7, 8, 9, 10) Over the past 2 weeks, have you been bothered by these problems?

Question Title

* 8. Feeling nervous, anxious, or on edge

Question Title

* 9. Not being able to stop or control worrying

Question Title

* 10. Feeling down, depressed, or hopeless

Question Title

* 11. Little interest or pleasure in doing things

(Questions 11 + 12) Below is a list of problems and complaints that people sometimes have in response to stressful experiences. Please read each one carefully, and circle the number that indicates how much you been bothered by that problem in the past month.

Question Title

* 12. Repeated, disturbing memories, thoughts, or images of a stressful experience?

Question Title

* 13. Feeling very upset when something reminded you of a stressful experience?

Question Title

* 14. Do you feel happy in general? Please choose a number: Not at all 0 1 2 3 4 5 6 7 8 9 10 Very

Question Title

* 15. Please indicate the intensity of current, best, and worst pain levels over the past 24 hours on a scale of 0 (no pain) to 10 (worst pain imaginable)

T