2020 Vibe~Check Evaluation

 What symptoms are you currently experiencing? (check all that apply):

    Red Eye flights                        ▢

    Blue balls                                 ▢

    Green-stained thumbs           ▢

    Blacking out                             ▢

    Yellow fever                             ▢

    Silver linings                             ▢ 

    Color blindness                        ▢ 

    

What medication/remedy/substance are you currently using:

    Orangade                        ◯

    Purple Syrup                   ◯

    White Noise                    ◯

    Brown Sugar                   ◯

    Mixed-grain Bread         ◯

    Water                               ◯

Fill in the grey box for additional comments and/or concerns:

(Blue or Black Ink only)