Christchurch Recovery

Name:

Your email address:

Contact phone number:

Age (years):

Gender:

Are you currently taking any medications? If Yes, please use the comments below to tell us what medications you are taking and for what conditions.

How many micronutrient pills are you currently taking per day (State zero if you have not started taking the pills yet)?

How many weeks have you been taking the micronutrient pills in total (State zero if you have not started taking the pills yet)?

Are you experiencing any problems associated with taking the micronutrient pills (N/A if not started taking the pills yet)? If Yes, please use the Comments section to describe the problems you are having.

I found it hard to wind down.

I was aware of dryness of my mouth.

I couldn't seem to experience any positive feeling at all.

I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion).

I found it difficult to work up the initiative to do things.

I tended to over-react to situations.

I experienced trembling (e.g. in the hands)

I felt that I was using a lot of nervous energy.

I was worried about situations in which I might panic and make a fool of myself.

I felt that I had nothing to look forward to.

I found myself getting agitated.

I found it difficult to relax.

I felt down-hearted and blue.

I was intolerant of anything that kept me from getting on with what I was doing.

I felt I was close to panic.

I was unable to become enthusiastic.

I felt I wasn't worth much as a person.

I felt that I was rather touchy.

I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat).

I felt scared without any good reason.

I felt that life meaningless.

Compared to when you started taking the pills, how much do you think your ANGER has changed?

Compared to when you started taking the pills, how much do you think your MOOD has changed?

Compared to when you started taking the pills, how much do you think your ANXIETY has changed?

Compared to when you started taking the pills, how much do you think your SLEEP has changed?

Compared to when you started taking the pills, how much do you think your ENERGY has changed?

Compared to when you started taking the pills, how much do you think you have changed OVERALL?

Please let us know if you have any questions, comments or concerns you would like to raise with the Mental Health and Nutrition Research Group: