Prexnova - LEVEL 7 Quiz

Anxiety Questionnaire Questions

First Name *

Last Name *

Phone *

Date of birth *

Email *

Privacy Notice & Client Consent

I understand that the information I provide in this consultation is personal health information and will be used solely for the purpose of guiding natural-health recommendations and support.
This information will be kept confidential and protected according to HIPAA privacy and security standards.

Privacy Consent *

I consent to the collection and use of my information as described above.

Compliance Notice

This quiz is for educational and wellness-support purposes only. It does not diagnose or treat medical conditions. Responses may be reviewed by a licensed provider to determine eligibility for a doctor-guided protocol. Individual results may vary.

Question 1

Anxiety can hit in different ways. Where does it affect you most? *

Racing thoughts or looping worry

Chest tightness, tension or shortness of breath

Trouble sleeping or staying asleep

Irritability or restlessness

In several of these ways at once

Question 2

How long have you been dealing with this level of anxiety? *

Less than 3 months

3–12 months

1–3 years

Over 3 years

Question 3

How intense or debilitating is it day-to-day? *

Mild — I notice it, but I can still function normally

Moderate — it shows up most days and affects focus or mood

Severe — it disrupts sleep, work, or relationships

Debilitating — it controls my day or triggers panic (e.g., can’t drive, cancel plans, constant dread)

Question 4

What have you tried to manage your anxiety with so far? *

Question 5

What has anxiety taken from you the most? *

Question 6

When does your anxiety tend to spike the most? *

In the morning — hard to get going

Midday — builds through stress or work

Evening — difficult to unwind

Overnight — wake with racing thoughts

Randomly — no clear pattern

Question 7

What seems to trigger or feed your anxiety the most? *

Question 8

What would a “win” look like for you in the next 30 days? *

Falling asleep easily and waking calm

Feeling centered and more in control

Handling stress without panic or overwhelm

Having steady energy and focus all day

Two or more of these improvements

Question 9

Many clients use commercial insurance to reduce the cost of this doctor protocol. Do you currently have coverage through an employer or private plan? *

Yes — I have commercial insurance (BCBS, Aetna, Cigna, etc.)

HSA/FSA/Self-Pay Cash