|
|
QUESTIONNAIRE FOR CERUM 7™ STUDY
Participant Name____________________________
Product Bottle Number_________
NOTE: Questions are to be asked and answers marked by nurse or assistant. The participant is NOT to see their prior responses.
NOTE: Initial week (week 0) the following four questions are asked
1. How is your energy level with 1 being low, 5 average and 10 being high.
_______
2. How frequent are your bowel movements? 1 being not often and 10 very often.
_______
3. How is your appetite? 1= Eat a little/hungry little 10 = Eat a lot/hungry often
_______
4. How much gas, bloating and indigestion do you have 1= none 10 = a lot
_______
Week 1 through 4 the following questions are asked.
On a scale of 1 to 10
1. What change have you noticed in your energy level?
1= A lot Less energy 5=no change 10=A lot more energy
Week 1_____ Week 2 _____ Week 3______ Week 4 _____
2.What change have you noticed in your frequency of bowel movements?
1=A lot less bowel movements 5=no change 10=A lot more bowel movements
Week 1_______ Week 2 _______ Week 3________ Week 4 _______
3.What change have you noticed in your appetite?
1= Eating a lot less 5=no change 10=Eating a lot more
Week 1_______ Week 2 _______ Week 3________ Week 4 _______
4.What change have you noticed in gas, bloating, and indigestion?
1= Less Gas, bloating and indigestion
5=no change
10=More Gas bloating and indigestion
Week 1_______ Week 2 _______ Week 3________ Week 4 _______
