• Patient Introduction

  • Personal History:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birth Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Neurotransmitter Assessment Form

    (NTAF)
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year

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

  • SECTION A

  • Is your memory noticeably declining?
  • Are you having a hard time remembering names and phone numbers?
  • Is your ability to focus noticeably declining?
  • Has it become harder for you to learn new things?
  • How often do you have a hard time remembering your appointments?
  • Is your temperament generally getting worse?
  • Is your attention span decreasing?
  • How often do you find yourself down or sad?
  • How often do you become fatigued when driving compared to in the past?
  • How often do you walk into rooms and forget why?
  • How often do you pick up your cell phone and forget why?

  • SECTION B

  • How high is your stress level?
  • How often do you feel you have something that must be done?
  • Do you feel you never have time for yourself?
  • How often do you feel you are not getting enough sleep or rest?
  • Do you find it difficult to get regular exercise?
  • Do you feel uncared for by the people in your life?
  • Do you feel you are not accomplishing your life’s purpose?
  • Is sharing your problems with someone difficult for you?

  • SECTION C

    SECTION C1
  • How often do you get irritable, shaky, or have light-headedness between meals?
  • How often do you feel energized after eating?
  • How often do you have difficulty eating large meals in the morning?
  • How often does your energy level drop in the afternoon?
  • How often do you crave sugar and sweets in the afternoon?
  • How often do you wake up in the middle of the night?
  • How often do you have difficulty concentrating before eating?
  • How often do you depend on coffee to keep yourself going?
  • How often do you feel agitated, easily upset, and nervous between meals?

  • SECTION C2
  • How often do you get fatigued after meals?
  • How often do you crave sugar and sweets after meals?
  • How often do you feel you need stimulants, such as coffee, after meals?
  • How often do you have difficulty losing weight?
  • How much larger is your waist girth compared to your hip girth?
  • How often do you urinate?
  • Have your thirst and appetite increased?
  • How often do you gain weight when under stress?
  • How often do you have difficulty falling asleep?

  • SECTION 1

  • Are you losing interest in hobbies?
  • How often do you feel overwhelmed?
  • How often do you have feelings of inner rage?
  • How often do you have feelings of paranoia?
  • How often do you feel sad or down for no reason?
  • How often do you feel like you are not enjoying life?
  • How often do you feel you lack artistic appreciation?
  • How often do you feel depressed in overcast weather?
  • How much are you losing your enthusiasm for your favorite activities?
  • How much are you losing your enjoyment for your favorite foods?
  • How much are you losing your enjoyment of friendships and relationships?
  • How often do you have difficulty falling into deep, restful sleep?
  • How often do you have feelings of dependency on others?
  • How often do you feel more susceptible to pain?
  • How often do you have feelings of unprovoked anger?
  • How much are you losing interest in life?

  • SECTION 2

  • How often do you have feelings of hopelessness?
  • How often do you have self-destructive thoughts?
  • How often do you have an inability to handle stress?
  • How often do you have anger and aggression while under stress?
  • How often do you feel you are not rested, even after long hours of sleep?
  • How often do you prefer to isolate yourself from others?
  • How often do you have unexplained lack of concern for family and friends?
  • How easily are you distracted from your tasks?
  • How often do you have an inability to finish tasks?
  • How often do you feel the need to consume caffeine to stay alert?
  • How often do you feel your libido has been decreased?
  • How often do you lose your temper for minor reasons?
  • How often do you have feelings of worthlessness?

  • SECTION 3

  • How often do you feel anxious or panicked for no reason?
  • How often do you have feelings of dread or impending doom?
  • How often do you feel knots in your stomach?
  • How often do you have feelings of being overwhelmed for no reason?
  • How often do you have feelings of guilt about everyday decisions?
  • How often does your mind feel restless?
  • How difficult is it to turn your mind off when you want to relax?
  • How often do you have disorganized attention?
  • How often do you worry about things you were not worried about before?
  • How often do you have feelings of inner tension and inner excitability?

  • SECTION 4

  • Do you feel your visual memory (shapes & images) has decreased?
  • Do you feel your verbal memory has decreased?
  • Do you have memory lapses?
  • Has your creativity decreased?
  • Has your comprehension diminished?
  • Do you have difficulty calculating numbers?
  • Do you have difficulty recognizing objects & faces?
  • Do you feel like your opinion about yourself has changed?
  • Are you experiencing excessive urination?
  • Are you experiencing a slower mental response?

  • Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition

  • Medication History

    Please check any of the following medications you have taken in the past or are currently taking
  • Noradrenergic and Specific Serotonergic Antidepressants (NaSSAas)
  • Tricyclic Antidepressants (TCAs)
  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
  • Selective Serotonin Reuptake Enhancers (SSREs)
  • Monoamine Oxidase Inhibitors (MAOIs)
  • Dopamine Receptor Agonists
  • D2 Dopamine Receptor Blockers (antipsychotics)
  • Agonist Modulators of GABA Receptors (benzodiazepines)
  • Agonist Modulators of GABA Receptors (non-benzodiazepines)
  • Acetylcholine Receptor Agonists
  • Acetylcholine Receptor Antagonists Antimuscarinic Agents
  • Acetylcholine Receptor Antagonists Ganglionic Blockers
  • Acetylcholine Receptor Antagonists Neuromuscular Blockers
  • Cholinesterase Inhibitors (reversible)
  • Cholinesterase Inhibitors (irreversible)

  • Metabolic Assessment Form

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • PART I

  • PART II

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

  • Category I

  • Feeling that bowels do not empty completely
  • Lower abdominal pain relieved by passing stool or gas
  • Alternating constipation and diarrhea
  • Diarrhea
  • Constipation
  • Hard, dry, or small stool
  • Coated tongue or “fuzzy” debris on tongue
  • Pass large amount of foul-smelling gas
  • More than 3 bowel movements daily
  • Use laxatives frequently

  • Category II

  • Increasing frequency of food reactions
  • Unpredictable food reactions
  • Aches, pains, and swelling throughout the body
  • Unpredictable abdominal swelling
  • Frequent bloating and distention after eating
  • Abdominal intolerance to sugars and starches

  • Category III

  • Intolerance to smells
  • Intolerance to jewelry
  • Intolerance to shampoo, lotion, detergents, etc
  • Multiple smell and chemical sensitivities
  • Constant skin outbreaks

  • Category IV

  • Excessive belching, burping, or bloating
  • Gas immediately following a meal
  • Offensive breath
  • Difficult bowel movements
  • Sense of fullness during and after meals
  • Difficulty digesting fruits and vegetables; undigested food found in stools

  • Category V

  • Stomach pain, burning, or aching 1-4 hours after eating
  • Use of antacids
  • Feel hungry an hour or two after eating
  • Heartburn when lying down or bending forward
  • Temporary relief by using antacids, food, milk, or carbonated beverages
  • Digestive problems subside with rest and relaxation
  • Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

  • Category VI

  • Roughage and fiber cause constipation
  • Indigestion and fullness last 2-4 hours after eating
  • Pain, tenderness, soreness on left side under rib cage
  • Excessive passage of gas
  • Nausea and/or vomiting
  • Stool undigested, foul smelling, mucous like, greasy, or poorly formed
  • Frequent urination
  • Increased thirst and appetite

  • Category VII

  • Greasy or high-fat foods cause distress
  • Lower bowel gas and/or bloating several hours after eating
  • Bitter metallic taste in mouth, especially in the morning
  • Burpy, fishy taste after consuming fish oils
  • Difficulty losing weight
  • Unexplained itchy skin
  • Yellowish cast to eyes
  • Stool color alternates from clay colored to normal brown
  • Reddened skin, especially palms
  • Dry or flaky skin and/or hair
  • History of gallbladder attacks or stones
  • Have you had your gallbladder removed?

  • Category VIII

  • Acne and unhealthy skin
  • Excessive hair loss
  • Overall sense of bloating
  • Bodily swelling for no reason
  • Hormone imbalances
  • Weight gain
  • Poor bowel function
  • Excessively foul-smelling sweat

  • Category IX

  • Crave sweets during the day
  • Irritable if meals are missed
  • Depend on coffee to keep going/get started
  • Get light-headed if meals are missed
  • Eating relieves fatigue
  • Feel shaky, jittery, or have tremors
  • Agitated, easily upset, nervous
  • Poor memory/forgetful
  • Blurred vision

  • Category X

  • Fatigue after meals
  • Crave sweets during the day
  • Eating sweets does not relieve cravings for sugar
  • Must have sweets after meals
  • Waist girth is equal or larger than hip girth
  • Frequent urination
  • Increased thirst and appetite
  • Difficulty losing weight

  • Category XI

  • Cannot stay asleep
  • Crave salt
  • Slow starter in the morning
  • Afternoon fatigue
  • Dizziness when standing up quickly
  • Afternoon headaches
  • Headaches with exertion or stress
  • Weak nails

  • Category XII

  • Cannot fall asleep
  • Perspire easily
  • Under a high amount of stress
  • Weight gain when under stress
  • Wake up tired even after 6 or more hours of sleep
  • Excessive perspiration or perspiration with little or no activity

  • Category XIII

  • Edema and swelling in ankles and wrists
  • Muscle cramping
  • Poor muscle endurance
  • Frequent urination
  • Frequent thirst
  • Crave salt
  • Abnormal sweating from minimal activity
  • Alteration in bowel regularity
  • Inability to hold breath for long periods
  • Shallow, rapid breathing

  • Category XIV

  • Tired/sluggish
  • Feel cold―hands, feet, all over
  • Require excessive amounts of sleep to function properly
  • Increase in weight even with low-calorie diet
  • Gain weight easily
  • Difficult, infrequent bowel movements
  • Depression/lack of motivation
  • Morning headaches that wear off as the day progresses
  • Outer third of eyebrow thins
  • Thinning of hair on scalp, face, or genitals, or excessive hair loss
  • Dryness of skin and/or scalp
  • Mental sluggishness

  • Category XV

  • Heart palpitations
  • Inward trembling
  • Increased pulse even at rest
  • Nervous and emotional
  • Insomnia
  • Night sweats
  • Difficulty gaining weight

  • Category XVI (Males Only)

  • Urination difficulty or dribbling
  • Frequent urination
  • Pain inside of legs or heels
  • Feeling of incomplete bowel emptying
  • Leg twitching at night

  • Category XVII (Males Only)

  • Decreased libido
  • Decreased number of spontaneous morning erections
  • Decreased fullness of erections
  • Difficulty maintaining morning erections
  • Spells of mental fatigue
  • Inability to concentrate
  • Episodes of depression
  • Muscle soreness
  • Decreased physical stamina
  • Unexplained weight gain
  • Increase in fat distribution around chest and hips
  • Sweating attacks
  • More emotional than in the past

  • Category XVIII (Menstruating Females Only)

  • Perimenopausal
  • Alternating menstrual cycle lengths
  • Extended menstrual cycle (greater than 32 days)
  • Shortened menstrual cycle (less than 24 days)
  • Pain and cramping during periods
  • Scanty blood flow
  • Heavy blood flow
  • Breast pain and swelling during menses
  • Pelvic pain during menses
  • Irritable and depressed during menses
  • Acne
  • Facial hair growth
  • Hair loss/thinning

  • Category XIX (Menopausal Females Only)

  • Since menopause, do you ever have uterine bleeding?
  • Hot flashes
  • Mental fogginess
  • Disinterest in sex
  • Mood swings
  • Depression
  • Painful intercourse
  • Shrinking breasts
  • Facial hair growth
  • Acne
  • Increased vaginal pain, dryness, or itching

  • PART III

  •

  • PART IV

  • Initial Consultation

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Would you like improvement with any of the following?:
  • How does this problem interfere with the following areas in your life?
  • Are you here visiting us to:
  • How have you taken care of your health in the past?
  • What are you afraid this might be or will be affecting without change?
  • Are there any health conditions you are afraid this might turn into?
  • What would be different or better without this problem?

  • Rate on a scale of 1-10:

  •
  • Should be Empty: