Child Ntaf

Child Neurotransmitter & Nutrition Questionnaire
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
General Diet
Does your child have any food sensitivities or allergies?

YesNo
If yes, please list:
List your child's 4 healthiest foods eaten during the average week:
List your child's 4 unhealthiest foods eaten during the average week:
How many times does your child eat candy per week?
How many times does your child drink soda per week?
List the top 4 foods your child craves regularly:
List the medication(s) your child is currently prescribed and any over-the-counter products used:
Do you find it difficult to have your child on a special diet?

YesNo
Evaluation Directions: Please check the appropriate number on all questions below. 0 indicates least/never and 3 indicates most/always.
Section A
Does your child eat pasta, breads, and breaded foods?

0123
Does your child have symptoms (fatigue, hyperactivity, etc.) after eating foods containing wheat/gluten?

0123
Does your child consume dairy products?

0123
Does your child have symptoms (fatigue, hyperactivity, etc.) after eating foods containing dairy products?

0123
Section B
Does your child eat fried fish?

0123
Does your child eat roasted seeds or nuts?

0123
Is your child missing essential fatty acid-rich foods in his/her diet? For example avocados, flax seeds, olives (use "0" if present, "3" if missing)

0123
Does your child eat fried foods?

0123
Section C
Is your child's mental speed slow?

0123
Does your child have difficulty with learning or memory?

0123
Does your child have difficulty with balancing and coordination?

0123
Section D
Does your child have stress?

0123
Does your child not have enough sleep and rest? (use "0" if enough and "3" if not enough)

0123
Does your child not have enough regular exercise? (use "0" if enough and "3" if no exercise)

0123
Does your child feel overly worried and scared?

0123
Section E
Does your child have temper tantrums?

0123
Does your child exhibit wild behavior?

0123
Does your child frequently yell or scream for unnecessary reasons?

0123
Does your child have an inability to nap or sleep when physically exhausted? (use "0" if able, "3" if unable)

0123
Is your child overly talkative?

0123
Does your child fidget and squirm when seated?

0123
Does your child run and climb excessively?

0123
Does your child have difficulty playing quietly or engaging in leisure activities?

0123
Section F
Does your child get excited easily?

0123
Does your child have anxiety and panic for minor reasons?

0123
Does your child feel overwhelmed for minor reasons?

0123
Does your child find it difficult to relax when he/she is awake?

0123
Does your child have disorganized attention?

0123
Section G
Does your child seem depressed?

0123
Does your child have mood changes with overcast weather?

0123
Does your child have symptoms of inner rage?

0123
Does your child seem uninterested in games or hobbies?

0123
Does your child have difficulty falling into deep, restful sleep?

0123
Does your child seem uninterested in friendship?

0123
Does your child have unprovoked anger?

0123
Does your child seem uninterested in eating?

0123
Section H
Does your child have difficulty handling stress?

0123
Does your child have anger and aggression while being challenged?

0123
Does your child feel tired even after many hours of sleep?

0123
Does your child tend to isolate himself/herself from others?

0123
Does your child get distracted easily?

0123
Does your child have a constant need and desire for candy and sugar?

0123
Does your child have unorganized attention?

0123
Section I
Does your child have difficulty with visual memory (shapes and images)?

0123
Does your child have difficulty remembering locations?

0123
Does your child have fatigue or low endurance for learning activities?

0123
Does your child have difficulty with attention or a short attention span?

0123
Does your child have slow or difficult speech?

0123
Does your child have uncoordinated or slow movements?

0123
Should be Empty:

Child Neurotransmitter & Nutrition Questionnaire

General Diet

Section A

Section B

Section C

Section D

Section E

Section F

Section G

Section H

Section I