|What are you taking?||Product/Products___________________________________________________|
|Dreaming During Sleep|
|Depression (if applicable)|
|Other Senses (hearing, smell, etc.)|
|Libido (sexual interest)|
|0= No Change||1= Slight Improvement||2= Fair Improvement||3= Good Improvement||4= Excellent Improvement|
Please print out several copies of the form above. Each one form covers a four week period. Please fill in the month and week of therapy you are recording and the dates. Please also write in the product/products you are taking. You may also add any areas of improvment that are pertinent to you in the blank rows.
We are always interested in knowing the specifics about how our clients are doing with our products so we will appreciate any client who sends us a copy of their completed progress forms.
ATTN: Lisa Wells, RN
5637 Hazeltine Ave
Sherman Oaks, CA 91401