Neurologic Symptoms & Supplement/Repurposed Medication Intake Form

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.Format: (000) 000-0000.
Age*
City / State / Country*
What brings you to this neurologic symptom review today?*
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)?*

YesNoNot sure
Which symptoms are you experiencing?*

TremorSlowness of movementMuscle stiffness or rigidityBalance problems or fallsShuffling gaitFreezing episodesHandwriting changesSpeech changesReduced facial expressionCognitive changes (memory, focus, processing)Confusion or disorientationDepression or low moodVisual disturbances (blurred vision, double vision, visual “snow,” difficulty focusing)Anxiety or irritabilitySleep disturbancesNumbness, tingling, or neuropathyMuscle twitching or spasmsOther
When did these symptoms begin?*
How are your symptoms changing over time?*
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)?*

YesNoNot sure
If yes, how did your symptoms respond?*

Significant improvementMild improvementNo improvementSymptoms worsenedNot sure
Supplement & Repurposed Medication Use

Tell us about any supplements or repurposed medications you are currently using.
Are you currently taking any supplements?*

YesNo
List all supplements you are taking, including dose and frequency.
Have you recently started, stopped, or changed any supplements?*
Are you taking any repurposed medications?*

YesNoNot sure
List all repurposed medications, including dose and frequency.
Have you taken any of the following botanicals or extracts?*

Soursop / GraviolaAcetogenin-containing botanicalsKavaSt. John’s WortValerianCBD / THCHigh-dose curcuminHigh-dose melatoninNoOther
Duration of use:*
Have you ever taken high-dose supplements for short periods?*

YesNoNot 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)?*

YesNoNot sure
If yes, please describe frequency, duration, and form.
Any history of environmental toxin exposure?

PesticidesHerbicidesHeavy metalsIndustrial chemicalsMoldOther
Medical & Lifestyle Context

Please provide information about your medical history and lifestyle.
Have you been evaluated by a neurologist?*

YesNoScheduled
If yes or scheduled, please provide details.
Any diagnosed medical conditions?
Current medications (non-supplement):
Sleep quality:*
Stress level:*
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?*

Sudden worsening of symptomsNew difficulty walkingNew or worsening confusionSudden severe depression or emotional changesNew or sudden visual disturbancesSudden severe headacheVision lossLoss of consciousnessNew weakness on one side of the bodyOther
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 harmingIdentify possible contributors to my neurologic symptomsLearn evidence-based strategies to support brain healthReview my supplement stack for safetyExplore coaching optionsOther
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:*

MildModerateSevereNot applicable
Frequency of depression:*

RarelySometimesOftenAlwaysNot applicable
Impact of depression on daily life:*
Severity of confusion:*

MildModerateSevereNot applicable
Frequency of confusion:*

RarelySometimesOftenAlwaysNot applicable
Impact of confusion on daily life:*
Severity of anxiety:*

MildModerateSevereNot applicable
Frequency of anxiety:*

RarelySometimesOftenAlwaysNot applicable
Impact of anxiety on daily life:*
Severity of visual disturbances:*

MildModerateSevereNot applicable
Frequency of visual disturbances:*

RarelySometimesOftenAlwaysNot 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*
Should be Empty:

Neurologic Symptoms & Repurposed Medication/Supplement Intake Form

Contact Information

Current Neurologic Symptoms

Dopamine‑Response Screening

Supplement & Repurposed Medication Use

Exposure & Risk Factors

Medical & Lifestyle Context

Safety Check

Coaching Goals

Neurologic Symptoms Associated with Ivermectin Use

Consent & Disclaimer