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
Name

First NameLast Name
Email
example@example.com
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?

NeverSometimesOftenAll the time
2. Do you notice an increase in depression around winter time?

NeverSometimesOftenAll the time
3. Do you enjoy staying up late at night on a regular basis?

NeverSometimesOftenAll the time
4. Do you have light sleep or wake up often at night?

NeverSometimesOftenAll the time
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?

NeverSometimesOftenAll the time
6. Do you have low self-esteem or lack confidence often?

NeverSometimesOftenAll the time
7. Do you easily get self-critical or feel guilty about things in your life?

NeverSometimesOftenAll the time
8. Do you crave sweet or starchy snacks or wine in the afternoons, evenings or late at night?

NeverSometimesOftenAll the time
9. Have you been diagnosed with fibromyalgia or suffer with unexplained muscle pain or TMJ (jaw tension and pain associated with grining the jaw)?

NeverSometimesOftenAll the time
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?

NeverSometimesOftenAll the time
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?

NeverSometimesOftenAll the time
12. Do you find yourself being irritable, impatient, edgy or angry more than you should?

NeverSometimesOftenAll the time
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?

NeverSometimesOftenAll the time
2. Do you struggle with constipation?

NeverSometimesOftenAll the time
3. Do you feel like your brain is running slower than it used too?

NeverSometimesOftenAll the time
4. Do you struggle with brain fog?

NeverSometimesOftenAll the time
5. Do you regularly forget where you have placed things (like your keys)?

NeverSometimesOftenAll the time
6. Do you find yourself making a lot of simple mistakes in your daily tasks?

NeverSometimesOftenAll the time
7. Do you have difficulty remembering lists, directions or instructions?

NeverSometimesOftenAll the time
8. Do you feel like you lack creativity or imagination?

NeverSometimesOftenAll the time
9. Do you have difficulty finding the right words before you speak?

NeverSometimesOftenAll the time
10. Do you feel disoriented at all throughout the day?

NeverSometimesOftenAll the time
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?

NeverSometimesOftenAll the time
2. Do you often feel depressed, flat, bored or apathetic?

NeverSometimesOftenAll the time
3. Do you feel like you lack physical or mental energy on a regular basis?

NeverSometimesOftenAll the time
4. Do you feel chronically tired, no matter how well you slept the night before?

NeverSometimesOftenAll the time
5. Is it challenging to focus or concentrate on things?

NeverSometimesOftenAll the time
6. Are you easily cold or do you notice you have cold hands or feet?

NeverSometimesOftenAll the time
7. Do you feel like you need stimulants like coffee and caffeine on a regular basis?

NeverSometimesOftenAll the time
8. Do you feel like you are struggling to perform at your best in your career or daily tasks?

NeverSometimesOftenAll the time
9. Are you lacking interest in sex?

NeverSometimesOftenAll the time
10. Are you struggling to finish projects or tasks you have started?

NeverSometimesOftenAll the time
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?

NeverSometimesOftenAll the time
2. Do you have trouble relaxing or loosening up?

NeverSometimesOftenAll the time
3. Is your body stiff and tight and takes time to loosen up?

NeverSometimesOftenAll the time
4. Are you easily upset and frustrated when under stress?

NeverSometimesOftenAll the time
5. Are you sensitive to bright light, chemical fumes or loud noises?

NeverSometimesOftenAll the time
6. Do you feel significantly worse if you skip meals or go a long time without eating?

NeverSometimesOftenAll the time
7. Do you feel overwhelmed or as though you just can’t get it all done?

NeverSometimesOftenAll the time
8. Do you have trouble shutting off your mind, especially at night when trying to sleep?

NeverSometimesOftenAll the time
9. Do you struggle with anxiety?

NeverSometimesOftenAll the time
10. Do you have a tendency to say things you wish you had not?

NeverSometimesOftenAll the time
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?

NeverSometimesOftenAll the time
2. Do you tend to avoid dealing with painful issues?

NeverSometimesOftenAll the time
3. Do you struggle to deal with loss, or grieving over deaths of friends or family?

NeverSometimesOftenAll the time
4. Do you suffer from chronic back pain or headaches?

NeverSometimesOftenAll the time
5. Taking pain killing medications doesn’t seem to offer any relief?

NeverSometimesOftenAll the time
6. Do you have a tendency to tear up easily?

NeverSometimesOftenAll the time
7. Do you crave pleasure and comfort foods like chocolate, bread, wine, etc?

NeverSometimesOftenAll the time
8. Do you feel like you don’t have any fun in your life?

NeverSometimesOftenAll the time
9. Do you feel super sensitive to pain? Light touch, light, sounds, etc. cause an aggravation of symptoms?

NeverSometimesOftenAll the time
10. Nobody seems to understand the amount of emotional pain you are carrying around?

NeverSometimesOftenAll the time
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:

Neurotransmitter Questionnaire

Wired & Tired

Memory Problems

Bored with Life

Stressed Out Mind

Sensitive and Hurting