Neurotransmitter Assessment

Neurotransmitter Assessment Form (NTAF)
Full Name

First NameLast Name
Date

MonthDayYear
Person(s) filling out questionnaire

First NameLast Name
Age
Gender

MaleFemale
Phone Number

Area CodePhone Number
Email
example@example.com
Please check the appropriate number on all questions below. 0 indicates least/never and 3 indicates most/always.
Section A
Is your memory noticeably declining?

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Are you having a hard time remembering names and phone numbers?

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Is your ability to focus noticeably declining?

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Has it become harder for you to learn new things?

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How often do you have a hard time remembering your appointments?

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Is your temperament generally getting worse?

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Is your attention span decreasing?

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How often do you find yourself down or sad?

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How often do you become fatigued when driving compared to in the past?

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How often do you become fatigued when reading compared to in the past?

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How often do you walk into rooms and forget why?

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How often do you pick up your cell phone and forget why?

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Section B
How high is your stress level?

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How often do you feel you have something that must be done?

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Do you feel you never have time for yourself?

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How often do you feel you are not getting enough sleep or rest?

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Do you find it difficult to get regular exercise?

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Do you feel uncared for by the people in your life?

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Do you feel you are not accomplishing your life's purpose?

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Is sharing your problems with someone difficult for you?

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Section C
How often do you get irritable, shaky, or have light-headedness between meals?

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How often do you feel energized after eating?

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How often do you have difficulty eating large meals in the morning?

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How often does your energy level drop in the afternoon?

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How often do you crave sugar and sweets in the afternoon?

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How often do you wake up in the middle of the night?

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How often do you have difficulty concentrating before eating?

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How often do you depend on coffee to keep yourself going?

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How often do you feel agitated, easily upset, and nervous between meals?

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Section C2
How often do you get fatigued after meals?

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How often do you crave sugar and sweets after meals?

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How often do you feel you need stimulants, such as coffee, after meals?

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How often do you have difficulty losing weight?

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How much larger is your waist girth compared to your hip girth?

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How often do you urinate?

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Have your thirst and appetite increased?

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How often do you gain weight when under stress?

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How often do you have difficulty falling asleep?

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Section 1
Are you losing interest in hobbies?

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How often do you feel overwhelmed?

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How often do you have feelings of inner rage?

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How often do you have feelings of paranoia?

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How often do you feel sad or down for no reason?

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How often do you feel like you are not enjoying life?

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How often do you feel you lack artistic appreciation?

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How often do you feel depressed in overcast weather?

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How much are you losing your enthusiasm for your favorite activities?

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How much are you losing your enjoyment for your favorite foods?

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How much are you losing your enjoyment of friendship and relationships?

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How often are you having difficulty falling into deep, restful sleep?

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How often do you have feelings of dependency on others?

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How often do you feel more susceptible to pain?

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How often do you have feelings of unprovoked anger?

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How much are you losing interest in life?

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Section 2
How often do you have feelings of hopelessness?

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How often do you have self-destructive thoughts?

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How often do you have an inability to handle stress?

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How often do you have anger and aggression while under stress?

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How often do you feel you are not rested, even after long hours of sleep?

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How often do you prefer to isolate yourself from others?

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How often do you have an unexplained lack of concern for family and friends?

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How easily are you distracted from your tasks?

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How often do you have an inability to finish tasks?

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How often do you feel the need to consume caffeine to stay alert?

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How often do you feel your libido has been decreased?

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How often do you lose your temper for minor reasons?

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How often do you have feelings of worthlessness?

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Section 3
How often do you feel anxious or panicked for no reason?

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How often do you have feelings of dread or impending doom?

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How often do you feel knots in your stomach?

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How often do you have feelings of being overwhelmed for no reason?

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How often do you have feelings of guilt about every day decisions?

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How often does your mind feel restless?

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How difficult is it to turn your mind off when you want to relax?

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How often do you have disorganized attention?

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How often do you worry about things you were not worried about before?

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How often do you have feelings of inner tension and inner excitability?

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Section 4
Do you feel your visual memory (shapes & images) has decreased?

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Do you feel your verbal memory has decreased?

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Do you have memory lapses?

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Has your creativity decreased?

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Has your comprehension diminished?

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Do you have difficulty calculating numbers?

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Do you have difficulty recognizing objects and faces?

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Do you feel like your opinion about yourself has changed?

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Are you experiencing excessive urination?

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Are you experiencing a slower mental response?

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Section 5
A decrease in mental alertness

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A decrease in mental speed

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A decrease in concentration quality

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Slow cognitive processing

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Impaired mental performance

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An increase in the ability to be distracted

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Need coffee or caffeine sources to improve mental function

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Should be Empty:

Neurotransmitter Assessment Form (NTAF)

Section A

Section B

Section C

Section C2

Section 1

Section 2

Section 3

Section 4

Section 5