Health Profile - Neurotransmitters
Complete this health intake form to help us understand your wellness status and needs.
Patient Information
Age
*
Gender
*
Male
Female
Email
*
example@example.com
Height (inches)
*
Weight (pounds)
*
Are you pregnant?
Yes
No
N/A
Are you nursing?
Yes
No
N/A
Medical History
Current or past conditions in last 2 years
*
Heart Disease
Cancer
Diabetes
High Blood Pressure
Urinary Tract Infections
Yeast/Fungal Infections
Thyroid Disease
Alcoholism/Drug Addiction
Irritable Bowel Syndrome/Crohn's/Colitis
Celiac Disease
Autoimmune Condition
PMS
None of these
Diagnosed conditions
*
Bipolar Disorder
Eating Disorder
Seizure Disorder
Panic Disorder or PTSD
OCD
Schizophrenia
Autism/PDD
ADD/ADHD
Alzheimer's or Dementia
Parkinson's
Kidney Disease
None of these
Head trauma in last 2 years?
*
Yes
No
Diet and Lifestyle
Current diet
Gluten Free
Dairy Free
Egg Free
Paleo
Ketogenic
Vegan
Vegetarian
None
Food sensitivities
Cow's Milk/Casein
Wheat/Gluten
Eggs
Soybeans
Corn
Fish
Shellfish
Tree Nuts
Peanuts
Pineapple
None
Food allergies
Cow's Milk/Casein
Wheat/Gluten
Eggs
Soybeans
Corn
Fish
Shellfish
Tree Nuts
Peanuts
Pineapple
None
Protein intake - 3-4 servings daily?
Yes
No
Exercise frequency
1-2x/week
3-4x/week
5+/week
Never
Water intake
1-2 glasses/day
3-5 glasses/day
6+/day
None
Caffeinated beverages per day
1-2 cups
3-5 cups
6+
None
Alcohol frequency
Never
Once a month or less
2-4 times a month
2-3 days a week
4+ days a week
Mood, Sleep, and Cognitive Symptoms
Depression or mood swings?
*
Yes
No
Sometimes
Future looks bleak or hopeless?
*
Yes
No
Suicidal ideations?
*
Yes
No
For immediate support call 911 or National Suicide Prevention Hotline 1-800-273-8255
Decreased energy for daily activities?
*
Yes
No
Stress level
*
Please Select
Normal
Low
High
Extremely High
Anxiety or nervousness?
*
Yes
No
Sometimes
Sleep issues
Falling Asleep
Staying Asleep
Occasionally
None
Memory issues?
*
Yes
No
Sometimes
Trouble focusing?
*
Yes
No
Sometimes
Headaches or migraines?
*
Yes
No
Sometimes
Symptoms and Medications
Cravings
Carbohydrates
Chocolate
Sugar
Salty Foods
Alcohol
Recreational Drugs
None
GI symptoms
Gas
Bloating
Trouble Digesting
Heartburn/Reflux
Belching
Frequent Bowel Movements
Constipation
Diarrhea
None
Gallbladder removed?
Yes
No
Can swallow capsules?
Yes
No
Medications for
Depression
Anxiety
Mood Disorders
Sleep
Focus
Blood Thinner
Cholesterol
Oral Contraceptives
Heartburn
None
Blood pressure medications
ACE inhibitors
Alpha blockers
Angiotensin II Blocker
Beta blockers
Calcium channel blockers
Diuretics
None
Regular use of
Medical Marijuana
CBD with THC
Hemp Oil/CBD Oil
Melatonin
Nicotine
Recreational Drugs
None
Antibiotic in last 6 months?
Yes
No
Current prescription medications with dosage
Current supplements with dosage
Top symptoms to address
Nitric oxide strip result
High
Target
Threshold
Low
Very Low
Submit
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