Brain Health & Nutrition Health Assessment Form

Name*

First NameLast Name

Pronouns:

Email*

example@example.com

Birthdate*

Date

Phone Number*

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please list your 5 major health concerns in order of importance:

Please fill in the appropriate number on all questions below. 0 as the least/never to 3 as the most/always

1- Brain Circulation

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
Low brain endurance for focus and concentration
Cold hands and feet
Must exercise or drink coffee to improve brain function
Poor nail health
Fungal growth on toenails
Must wear socks at night
Nail beds are white instead of pink
The tip of the nose is cold

2- Sugar Metabolism

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
Irritable, nervous, shaky, or light-headed between meals
Feel energized after meals
Difficulty eating large meals in the morning
Energy level drops in the afternoon
Crave sugar and sweets in the afternoon
Wake up in the middle of the night
Difficulty concentrating before eating
Depend on coffee to keep going

3- Peripheral Utilization of Sugars

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
Fatigue after meals
Sugar and sweet cravings after meals
Need for a stimulant, such as coffee, after meals
Difficulty losing weight
Increased frequency of urination
Difficulty falling asleep
Increased appetite

4- Stress and the Brain

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
Always have projects and things that need to be done
Never have time for yourself
Not getting enough sleep or rest
Difficulty getting regular exercise
Feel that you are not accomplishing your life’s purpose

5- Essential Fatty Acids

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
Dry and unhealthy skin
Dandruff or a flaky scalp
Consumption of processed foods that are bagged or boxed
Consumption of fried foods
Difficulty consuming raw nuts or seeds
Difficulty consuming fish (not fried)
Difficulty consuming olive oil, avocados, flax seed oil, or natural fats

6- Brain-Gut Axis

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
Difficulty digesting foods
Constipation or inconsistent bowel movements
Increased bloating or gas
Abdominal distention after meals
Difficulty digesting protein-rich foods
Difficulty digesting starch-rich foods
Difficulty digesting fatty or greasy foods
Difficulty swallowing supplements or large bites of food
Abnormal gag reflex

7- Brain-Immune Axis

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
Brain fog (unclear thoughts or concentration)
Pain and inflammation
Noticeable variations in mental speed
Brain fatigue after meals
Brain fatigue after exposure to chemicals, scents, or pollutants
Brain fatigue when the body is inflamed

8- Gluten Digestion

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
Grain consumption leads to tiredness
Grain consumption makes it difficult to focus and concentrate
Feel better when bread and grains are avoided
Grain consumption causes the development of any symptoms
A 100% gluten-free diet

9- Intestinal Barrier

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
A diagnosis of celiac disease, gluten sensitivity, hypothyroidism, or an autoimmune disease
Family members who have been diagnosed with an autoimmune disease
Family members who have been diagnosed with celiac disease or gluten sensitivity
Changes in brain function with stress, poor sleep, or immune activation

10- Serotonin

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
A loss of pleasure in hobbies and interests
Feel overwhelmed with ideas to manage
Feelings of inner rage or unprovoked anger
Feelings of paranoia
Feelings of sadness for no reason
A loss of enjoyment in life
A lack of artistic appreciation
Feelings of sadness in overcast weather
A loss of enthusiasm for favorite activities
A loss of enjoyment in favorite foods
A loss of enjoyment in friendships and relationships
Inability to fall into deep, restful sleep
Feelings of dependency on others
Feelings of susceptibility to pain

11- Dopamine

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
Feelings of worthlessness
Feelings of hopelessness
Self-destructive thoughts
Inability to handle stress
Anger and aggression while under stress
Feelings of tiredness, even after many hours of sleep
A desire to isolate yourself from others
An unexplained lack of concern for family and friends
An inability to finish tasks
Feelings of anger for minor reasons

12- Acetylcholine

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
A decrease in visual memory (shapes and images)
A decrease in verbal memory
Occurrence of memory lapses
A decrease in creativity
A decrease in comprehension
Difficulty calculating numbers
Difficulty recognizing objects and faces
A change in opinion about yourself
Slow mental recall

13- Catecholamines

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
A decrease in mental alertness
A decrease in mental speed
A decrease in concentration quality
Slow cognitive processing
Impaired mental performance
An increase in the ability to be distracted
Need coffee or caffeine sources to improve mental function

14- Gaba

Rows	0- Least/ Never	1-Sometimes	2- Often	3- Mostly
Feelings of nervousness or panic for no reason
Feelings of dread
Feelings of a “knot” in your stomach
Feelings of being overwhelmed for no reason
Feelings of guilt about everyday decisions
A restless mind
An inability to turn off the mind when relaxing
Disorganized attention
Worry over things never thought about before
Feelings of inner tension and inner excitability

Brain Health and Nutrition Assessment Form