CRT Brain Chemistry Sample Questionnaires

Thanks for your interest in CRT and your Stress Story.

Following are sample questionnaires to help us assess imbalances in your brain chemistry.

Complete the questions, then call us for an appointment to go more in-depth. Ph. 309.751.9790.

Sample Questionnaires

Questionnaire #1

Check each of the sentences below that applies to you.

____ Your life seems complete.

____ You feel shy with all your closest friends.

____ You have feelings of insecurity.

____ You often feel unequal to others.

____ When things go right, you feel undeserving.

____ You feel something is missing in your life.

____ You occasionally feel a low self-worth or self-esteem.

____ You feel inadequate as a person.

____ You frequently feel fearful when there is nothing to fear.

If three or more of these descriptions apply to your present feelings, you are aligned with this group.

Questionnaire #2

Check each of the sentences below that applies to you.

____ You often feel anxious for no reason.

____ You sometimes feel "free-floating anxiety".

____ You frequently feel "edgy" and it's difficult to relax.

____ You often feel a "knot" in your stomach.

____ Falling asleep is sometimes difficult.

____ It's hard to turn your mind off when you want to relax.

____ You occasionally experience feelings of panic for no reason.

____ You often use alcohol or other sedatives to calm down.

If three or more of these descriptions apply to your present feelings, you are aligned with this group.

Questionnaire #3

Check each of the sentences below that applies to you.

____ You lack pleasure in life.

____ You feel there are no real rewards in life.

____ You have unexplained lack of concern for others, even loved ones.

____ You experience decreased parental feelings.

____ Life seems less "colorful" or "flavorful".

____ Things that used to be "fun" just aren't any longer.

____ You have become a less spiritual or socially concerned person.

If three or more of these descriptions apply to your present feelings, you are aligned with this group.

Questionnaire #4

Check each of the sentences below that applies to you.

____ You suffer from a lack of energy.

____ You often find it difficult to "get going".

____ You suffer from decreased drive.

____ You often start projects and then don't finish them.

____ You frequently feel a need to sleep or "hibernate".

____ You feel depressed a good deal of the time.

____ You occasionally feel paranoid.

____ Your survival seems threatened.

____ You are bored a great deal of the time.

If three or more of these descriptions apply to your present feelings, you are aligned with this group.

In the office, we'll work through longer, more extensive questionnaires which will present a thorough picture of your brain chemistry. Then with CRT and nutritional supplements, we'll bring your body into balance.

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Cranial Release Technique (CRT) is a powerful and simple technique to release stress-related tension in the nervous system.