Neurotransmitter Questionnaire

  • Neurotransmitter Questionnaire

    The goal of this questionnaire is to see if your body is struggling to produce one or more of the major neurotransmitters involved in healthy brain function

  • Fill this out as accurately as possible and add up your points to see your score

    Never = 0 points

    Sometimes = 1pt

    Often = 2 pts

    All the time = 3 pts

  • Wired & Tired

    Section One
  • 1. Do you suffer with frequent worry or anxiety?
  • 2. Do you notice an increase in depression around winter time?
  • 3. Do you enjoy staying up late at night on a regular basis?
  • 4. Do you have light sleep or wake up often at night?
  • 5. Do you get PMS or deal with menopausal moodiness (anger, sadness, depression, tears)? (If you are a woman of course). For men, do you experience moodiness?
  • 6. Do you have low self-esteem or lack confidence often?
  • 7. Do you easily get self-critical or feel guilty about things in your life?
  • 8. Do you crave sweet or starchy snacks or wine in the afternoons, evenings or late at night?
  • 9. Have you been diagnosed with fibromyalgia or suffer with unexplained muscle pain or TMJ (jaw tension and pain associated with grining the jaw)?
  • 10. Does your behaviour ever get obsessive? Hard to be flexible with your plans, you are a perfectionist in your work or a neatfreak, or a control freak?
  • 11. Do you find yourself easily addicted to work, a TV show or a video game, a food, sugar, alcohol, smoking, sex or anything else?
  • 12. Do you find yourself being irritable, impatient, edgy or angry more than you should?

  • Total Score________________

    If you score a 20 or above, you are probably experiencing symptoms of low serotonin. Serotonin is an inhibitory neurotransmitter and depletion of such can cause poor sleep, depression and anxiety.

  • Memory Problems

    Section 2
  • 1. Do you have trouble remembering words, phrases or names?
  • 2. Do you struggle with constipation?
  • 3. Do you feel like your brain is running slower than it used too?
  • 4. Do you struggle with brain fog?
  • 5. Do you regularly forget where you have placed things (like your keys)?
  • 6. Do you find yourself making a lot of simple mistakes in your daily tasks?
  • 7. Do you have difficulty remembering lists, directions or instructions?
  • 8. Do you feel like you lack creativity or imagination?
  • 9. Do you have difficulty finding the right words before you speak?
  • 10. Do you feel disoriented at all throughout the day?

  • Total Score:_____________

    If your score is 18 or above you may have problems with acetylcholine deficiency. Acetylcholine is an excitatory neurotransmitter that is involved with learning, memory, imagination, creativity and cognitive acceleration.

  • Bored with Life

    Section 3
  • 1. Is your drive, enthusiasm and motivation in life lacking?
  • 2. Do you often feel depressed, flat, bored or apathetic?
  • 3. Do you feel like you lack physical or mental energy on a regular basis?
  • 4. Do you feel chronically tired, no matter how well you slept the night before?
  • 5. Is it challenging to focus or concentrate on things?
  • 6. Are you easily cold or do you notice you have cold hands or feet?
  • 7. Do you feel like you need stimulants like coffee and caffeine on a regular basis?
  • 8. Do you feel like you are struggling to perform at your best in your career or daily tasks?
  • 9. Are you lacking interest in sex?
  • 10. Are you struggling to finish projects or tasks you have started?

  • Total Score:__________

    If your score is 18 or above than you are probably experiencing symptoms of low dopamine, epinephrine and norepinephrine. These are excitatory neurotransmitters that give us drive, ambition and passion when they are in balance.

  • Stressed Out Mind

    Section 4
  • 1. Do you regularly feel overworked or like you are falling behind with your daily tasks?
  • 2. Do you have trouble relaxing or loosening up?
  • 3. Is your body stiff and tight and takes time to loosen up?
  • 4. Are you easily upset and frustrated when under stress?
  • 5. Are you sensitive to bright light, chemical fumes or loud noises?
  • 6. Do you feel significantly worse if you skip meals or go a long time without eating?
  • 7. Do you feel overwhelmed or as though you just can’t get it all done?
  • 8. Do you have trouble shutting off your mind, especially at night when trying to sleep?
  • 9. Do you struggle with anxiety?
  • 10. Do you have a tendency to say things you wish you had not?

  • Total Score:_____________

    If your score is 15 or more than you are probably experiencing symptoms associated with GABA deficiency and adrenal fatigue. GABA is an inhibitory neurotransmitter that calms the mind and helps to bring peace and relaxation to both the mind and body.

  • Sensitive and Hurting

    Section 5
  • 1. Do you people tell you that you are too sensitive?
  • 2. Do you tend to avoid dealing with painful issues?
  • 3. Do you struggle to deal with loss, or grieving over deaths of friends or family?
  • 4. Do you suffer from chronic back pain or headaches?
  • 5. Taking pain killing medications doesn’t seem to offer any relief?
  • 6. Do you have a tendency to tear up easily?
  • 7. Do you crave pleasure and comfort foods like chocolate, bread, wine, etc?
  • 8. Do you feel like you don’t have any fun in your life?
  • 9. Do you feel super sensitive to pain? Light touch, light, sounds, etc. cause an aggravation of symptoms?
  • 10. Nobody seems to understand the amount of emotional pain you are carrying around?

  • Total Score:_______________

    If your score is 15 or more you are probably experiencing symptoms associated with a loss of endorphins. Endorphins are feel good molecules your body produces that block pain receptors and give a sense of joy and euphoria.

  • Should be Empty: