*Brain Health Evaluation

Brain Health Evaluation
Serotonin
1. Feel depressed, unhappy, or sad

NoMildModerateSevere
2. You can’t stay asleep and/or lack of deep restorative sleep

NoMildModerateSevere
3. Compulsive behavior, unprovoked anger and/or unexplained crying

NoMildModerateSevere
Serotonin %
Dopamine
4. Feel anxious or have social phobia

NoMildModerateSevere
5. Have addictive personality; Past/present troubles with alcohol, food, pharmaceutical and recreational drugs.

NoMildModerateSevere
6. Have troubles staying focused on one particular task

NoMildModerateSevere
7. Life seems less fun, colorful or flavorful, lack pleasure

NoMildModerateSevere
Dopamine %
Acetylcholine
8. Lapses in memory

NoMildModerateSevere
9. Difficulty comprehending verbal instructions

NoMildModerateSevere
Acetylcholine %
Gaba
10. Feel tense and/or have troubles turning your mind off when you want to relax

NoMildModerateSevere
11. Feel irritable, crabby or short tempered

NoMildModerateSevere
12. You often use alcohol or other sedatives to calm down

NoMildModerateSevere
Gaba %
Stress
13. Current level of stress

NoMildModerateSevere
14. Feelings of hopelessness

NoMildModerateSevere
15. Feelings of being overwhelmed

NoMildModerateSevere
16. Events from the past cause you pain, resentment or anger

NoMildModerateSevere
17. Worry about the future or current situation you are in (finances, health, work, family, lack of purpose, lack of certainty)

NoMildModerateSevere
Stress %
Nervous System Total %
Please list your top 5 complaints. If you don’t have 5 that is okay.
1
2
3
4
5
Contact Information
First Name*
Last Name*
Email*
SMS #*
State
Please verify that you are human*
utm_source
utm_campaign
Should be Empty:

Brain Health Evaluation

Serotonin

Dopamine

Acetylcholine

Gaba

Stress

Please list your top 5 complaints. If you don’t have 5 that is okay.

Contact Information