Brainchamp Questionnaire (Form 101)
Brainchamp ID
PHYSICAL HEALTH & ENERGY
1. How consistently do you feel energized throughout the day?
*
1
2
3
4
5
never
always
2. How free are you from pain interfering with daily tasks?
*
1
2
3
4
5
never
always
3. What is your own sense of general health and wellness?
*
1
2
3
4
5
very poor
really well
4. How often do you experience physical unsteadiness or postural challenges?
*
1
2
3
4
5
always
never
5. How often do you have feelings of bloating, fullness, or unease?
*
1
2
3
4
5
always
never
SLEEP & REST
6. How would you rate your restorative and undisturbed sleep patterns?
*
1
2
3
4
5
very poor
really well
7. Do you get the recommended hours of sleep per night (7-9hrs)?
*
1
2
3
4
5
never
always
8. How rested do you typically feel upon waking?
*
1
2
3
4
5
not rested at all
very rested
9. How often do you rely on caffeine during the day?
*
1
2
3
4
5
always
never
10. How often do you have irregular sleep?
*
1
2
3
4
5
always
never
11. How regularly do you go to sleep at the same time?
*
1
2
3
4
5
never
always
12. How often do you reduce screen time before sleep?
*
1
2
3
4
5
never
always
13. How often do you use relaxation before bed?
*
1
2
3
4
5
never
always
COGNITIVE FUNCTION
14. How clear, alert, and attentive do you feel during the day?
*
1
2
3
4
5
never
always
15. How often do you have daytime fogginess or trouble focusing?
*
1
2
3
4
5
always
never
16. How often do you have trouble recalling or concentrating on information?
*
1
2
3
4
5
always
never
17. How often do you have brain fog or slow processing?
*
1
2
3
4
5
always
never
EMOTIONAL WELL-BEING
18. How would you rate your general emotional state and positivity?
*
1
2
3
4
5
very poor
really well
19. How effectively do you express and process emotions?
*
1
2
3
4
5
very poor
really well
20. What is your ability to calm yourself when distressed?
*
1
2
3
4
5
very poor
really well
21. How positively do you view the future?
*
1
2
3
4
5
very negative
very positive
22. What are your current levels of anxiousness and internal stress?
*
1
2
3
4
5
very high
very low
23. How often do you experience emotional reactivity or short-temperedness?
*
1
2
3
4
5
always
never
RECOVERY & RESILIENCE
24. Overall, how well do you feel you bounce back mentally and physically?
*
1
2
3
4
5
not confident
very confident
25. What is your sense of physical/emotional recovery day-to-day?
*
1
2
3
4
5
very poor
very well
PERSONAL EMPOWERMENT & PURPOSE
26. How would you rate your belief in your ability to manage challenges?
*
1
2
3
4
5
not confident
very confident
27. How would you rate your clarity and connection to your values or 'why'?
*
1
2
3
4
5
very poor
very well
SOCIAL & ENVIRONMENTAL SUPPORT
28. How would you rate your perceived connection and trust with others?
*
1
2
3
4
5
very poor
very well
29. Do you have clean, safe, and wellness-supportive living spaces?
*
1
2
3
4
5
not at all
always
MAJOR LIFE STRESSORS (within the past 12 months)
30. What is the emotional impact from the death of loved ones?
*
1
2
3
4
5
high impact
low impact
31. How disruptive have major injuries or illnesses been to your life?
*
1
2
3
4
5
high impact
low impact
32. How impactful has a relationship breakdown been (e.g., divorce, separation)?
*
1
2
3
4
5
high impact
low impact
33. How significant has an employment change been (e.g., job loss, transition)?
*
1
2
3
4
5
high impact
low impact
34. How impactful has relocation or instability been to your living environment?
*
1
2
3
4
5
high impact
low impact
35. How challenging has the military/civilian transition been?
*
1
2
3
4
5
high impact
low impact
36. How significant has exposure to violence or trauma been?
*
1
2
3
4
5
high impact
low impact
37. How persistent are your worries about financial security?
*
1
2
3
4
5
high impact
low impact
38. How impactful have legal or criminal issues been?
*
1
2
3
4
5
high impact
low impact
39. How frequent is conflict with others (e.g., family or peers)?
*
1
2
3
4
5
high impact
low impact
40. How significant has discrimination or marginalization been?
*
1
2
3
4
5
high impact
low impact
41. How impactful have life-threatening events been?
*
1
2
3
4
5
high impact
low impact
42. Specify and rate the impact of other life stressors.
*
1
2
3
4
5
high impact
low impact
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