Neurologic Symptoms & Repurposed Medication/Supplement Intake Form
Please complete this intake form to help us understand your current neurologic symptoms, supplement use, and relevant risk factors. This information supports your coaching process.
Contact Information
Please provide your basic contact details.
Full Name
*
Email Address
*
example@example.com
Phone Number (Optional)
Please enter a valid phone number.
Age
*
City / State / Country
*
What brings you to this neurologic symptom review today?
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Current Neurologic Symptoms
Select all symptoms you are currently experiencing.
Do you notice any improvement in your symptoms after activities that boost dopamine (e.g., exercise, enjoyable activities, certain foods)?
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Yes
No
Not sure
Which symptoms are you experiencing?
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Tremor
Slowness of movement
Muscle stiffness or rigidity
Balance problems or falls
Shuffling gait
Freezing episodes
Handwriting changes
Speech changes
Reduced facial expression
Cognitive changes (memory, focus, processing)
Confusion or disorientation
Depression or low mood
Visual disturbances (blurred vision, double vision, visual “snow,” difficulty focusing)
Anxiety or irritability
Sleep disturbances
Numbness, tingling, or neuropathy
Muscle twitching or spasms
Other
When did these symptoms begin?
*
Please Select
Within the last week
1–4 weeks ago
1–6 months ago
6–12 months ago
Over a year ago
How are your symptoms changing over time?
*
Please Select
Getting better
Getting worse
Staying the same
Fluctuating day to day
Dopamine‑Response Screening
Your responses help us understand if dopamine-related factors may play a role.
Have you ever been prescribed dopamine‑based medications (levodopa, carbidopa, dopamine agonists)?
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Yes
No
Not sure
If yes, how did your symptoms respond?
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Significant improvement
Mild improvement
No improvement
Symptoms worsened
Not sure
Supplement & Repurposed Medication Use
Tell us about any supplements or repurposed medications you are currently using.
Are you currently taking any supplements?
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Yes
No
List all supplements you are taking, including dose and frequency.
Have you recently started, stopped, or changed any supplements?
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Are you taking any repurposed medications?
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Yes
No
Not sure
List all repurposed medications, including dose and frequency.
Have you taken any of the following botanicals or extracts?
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Soursop / Graviola
Acetogenin-containing botanicals
Kava
St. John’s Wort
Valerian
CBD / THC
High-dose curcumin
High-dose melatonin
No
Other
Duration of use:
*
Please Select
Less than 1 week
1–4 weeks
1–6 months
6–12 months
Over a year
Have you ever taken high-dose supplements for short periods?
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Yes
No
Not sure
If yes, please describe.
Exposure & Risk Factors
Please select any relevant exposures or risk factors.
Have you ever consumed soursop (fruit, tea, leaves, extracts, supplements)?
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Yes
No
Not sure
If yes, please describe frequency, duration, and form.
Any history of environmental toxin exposure?
Pesticides
Herbicides
Heavy metals
Industrial chemicals
Mold
Other
Medical & Lifestyle Context
Please provide information about your medical history and lifestyle.
Have you been evaluated by a neurologist?
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Yes
No
Scheduled
If yes or scheduled, please provide details.
Any diagnosed medical conditions?
Current medications (non-supplement):
Sleep quality:
*
Please Select
Excellent
Good
Fair
Poor
Stress level:
*
Please Select
Low
Moderate
High
Very high
Describe your general dietary pattern:
Safety Check
Please indicate if you have experienced any of the following symptoms.
Have you experienced any of the following?
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Sudden worsening of symptoms
New difficulty walking
New or worsening confusion
Sudden severe depression or emotional changes
New or sudden visual disturbances
Sudden severe headache
Vision loss
Loss of consciousness
New weakness on one side of the body
Other
If you selected any of the above, please describe.
Coaching Goals
Help us understand your priorities for this review.
What are your top goals for this review?
*
Understand whether my supplements are helping or harming
Identify possible contributors to my neurologic symptoms
Learn evidence-based strategies to support brain health
Review my supplement stack for safety
Explore coaching options
Other
Is there anything else you want me to know before your session?
Neurologic Symptoms Associated with Ivermectin Use
Please evaluate the following symptoms related to ivermectin use.
Severity of depression:
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Mild
Moderate
Severe
Not applicable
Frequency of depression:
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Rarely
Sometimes
Often
Always
Not applicable
Impact of depression on daily life:
*
Severity of confusion:
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Mild
Moderate
Severe
Not applicable
Frequency of confusion:
*
Rarely
Sometimes
Often
Always
Not applicable
Impact of confusion on daily life:
*
Severity of anxiety:
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Mild
Moderate
Severe
Not applicable
Frequency of anxiety:
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Rarely
Sometimes
Often
Always
Not applicable
Impact of anxiety on daily life:
*
Severity of visual disturbances:
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Mild
Moderate
Severe
Not applicable
Frequency of visual disturbances:
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Rarely
Sometimes
Often
Always
Not applicable
Impact of visual disturbances on daily life:
*
Consent & Disclaimer
Please review and confirm the following statements.
Please confirm the following:
*
I understand this review is for educational purposes only.
I understand this is not medical care, diagnosis, or treatment.
I agree to consult my healthcare team for medical decisions.
Signature
*
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