What is your gender?
*
Male
Female
Non-Binary
1/17
What’s your age?
*
18-24
25-35
35-44
45-54
55-64
65+
2/17 ***We only use your age for your dopamine profile***
How easy is for you to become distracted?
*
Easily distracted
Occasionally get distracted
Rarely get distracted
Never distracted
4/17
How frequently do you feel compelled to check your phone or social media?
*
At least once per hour
Every couple of hours
1-2 times per day
Rarely check
5/17
How often do you watch YouTube or scroll on social media while eating?
*
Almost always
Often
Rarely
Never
6/17
Do you wait until the last moment to do things?
*
All the time
Often
Rarely
Never
7/17
What do you do within the first 10 minutes of waking up?
*
Pick up my phone
Drink coffee
Brush my teeth
Other
8/17
I feel tired all day, no matter how much sleep I get.
*
Almost always
Sometimes
Rarely
Never
9/17
Do you feel bad, angry or sad when you procrastinate?
*
Almost always
Sometimes
Rarely
Never
10/17
I don’t feel joyful to do the things I used to love.
*
Strongly Disagree
Somewhat Disagree
Somewhat Agree
Strongly Agree
11/17
When was the last time you felt consistently motivated and driven?
*
This week
A few weeks ago
A few months ago
1-2 years ago
3+ years ago
Never
12/17
How often do you feel stressed or worried?
*
All the time
Often
Rarely
Never
13/17
How often do you feel overwhelmed by the amount of work you have to do?
*
Almost Always
Sometimes
Rarely
Never
14/17
Is your sleep charaterized by any of the following?
*
Difficulty falling asleep
Difficulty staying asleep
Waking up tired
Unpredictable sleep schedule
I rarely or never dream
I sleep well
15/17 ***Choose all that apply to you***
What is your First Name?
*
16/17
What is your Email?
*
We will send you our 30-Day Dopamine Reboot Guide and Free Access to the Born Free Private Community Platform - Your results will appaear on the next slide.