Energy Survey

Maintaining good energy levels is vital to staying healthy. If you suffer from excessively high energy or low energy, it can be difficult to function and be productive. Don’t let energy symptoms like fatigue or restlessness affect your day. Take this short quiz to help us get a better understanding of your energy symptoms and see how we can help you boost your energy with our Living Well Program.

Please fill out this short survey including your contact information so that we can contact you further if needed. Your information will remain safe and confidential.

Rate each of the following based on your health in the last 90 days:

  • 0 = Rarely or never experience the symptom
  • 1 = Occasionally experience but effect is not severe
  • 2 = Occasionally experience but effect is severe
  • 3 = Frequently experience and effect is not severe
  • 4 = Frequently experience and effect is severe
  • 01234
  • 01234
  • 01234
  • 01234
  • 01234
  • 01234
  • 01234