Form – Child Neurotransmitter and Nutrition Questionnaire (CNNQ) Name(Required)Age:SexDate MM slash DD slash YYYY Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.SECTION: GENERAL DIETDoes your child have any food sensitivities or allergies? (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 regularlyList 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?SECTION ADoes your child eat pasta, breads, and breaded foods? 0 1 2 3 Does your child have symptoms (fatigue, hyperactivity, etc) after eating foods containing wheat/gluten? 0 1 2 3 Does your child consume dairy products? 0 1 2 3 Does your child have symptoms (fatigue, hyperactivity, etc) after consuming dairy products? 0 1 2 3 SECTION BDoes your child eat fried fish? 0 1 2 3 Does your child eat roasted nuts or seeds? 0 1 2 3 Is your child missing essential fatty acid-rich foods in his/her diet? (for example: avocados, flax seeds, olives) 0 1 2 3 (circle “0” if present, “3” if missing) Does your child eat fried foods? 0 1 2 3 SECTION CIs your child’s mental speed slow? 0 1 2 3 Does your child have difficulty with learning or memory? 0 1 2 3 Does your child have difficulty with balance and coordination? 0 1 2 3 SECTION DDoes your child have stress? 0 1 2 3 Does your child not have enough sleep and rest? 0 1 2 3 (circle “0” if enough, “3” if not enough)Does your child not have regular exercise? 0 1 2 3 (circle “0” if regular exercise, “3” if no exercise)Does your child feel overly worried and scared? 0 1 2 3 SECTION EDoes your child have temper tantrums? 0 1 2 3 Does your child exhibit wild behavior? 0 1 2 3 Does your child frequently yell or scream for unnecessary reasons? 0 1 2 3 Does your child have an inability to nap or sleep when physically exhausted? 0 1 2 3 (circle “0” if able, “3” if unable) Is your child overly talkative? 0 1 2 3 Does your child fidget and squirm when seated? 0 1 2 3 Does your child run and climb excessively? 0 1 2 3 Does your child have difficulty playing quietly or engaging in leisure activities? 0 1 2 3 SECTION FDoes your child get excited easily? 0 1 2 3 Does your child have anxiety and panic for minor reasons? 0 1 2 3 Does your child feel overwhelmed for minor reasons? 0 1 2 3 Does your child find it difficult to relax when he/she is awake? 0 1 2 3 Does your child have disorganized attention? 0 1 2 3 SECTION GDoes your child seem depressed? 0 1 2 3 Does your child have mood changes with overcast weather? 0 1 2 3 Does your child have symptoms of inner rage? 0 1 2 3 Does your child seem uninterested in games or hobbies? 0 1 2 3 Does your child have difficulty falling into deep, restful sleep? 0 1 2 3 Does your child seem uninterested in friendships? 0 1 2 3 Does your child have unprovoked anger? 0 1 2 3 Does your child seem uninterested in eating? 0 1 2 3 SECTION HDoes your child have difficulty handling stress? 0 1 2 3 Does your child have anger and aggression while being challenged? 0 1 2 3 Does your child feel tired even after many hours of sleep? 0 1 2 3 Does your child tend to isolate himself/herself from others? 0 1 2 3 Does your child get distracted easily? 0 1 2 3 Does your child have a constant need and desire for candy and sugar? 0 1 2 3 Does your child have disorganized attention? 0 1 2 3 SECTION IDoes your child have difficulty with visual memory (shapes and images)? 0 1 2 3 Does your child have difficulty remembering locations? 0 1 2 3 Does your child have fatigue or low endurance for learning activities? 0 1 2 3 Does your child have difficulty with attention or a short attention span? 0 1 2 3 Does your child have slow or difficult speech? 0 1 2 3 Does your child have uncoordinated or slow movements? 0 1 2 3 Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.CAPTCHANameThis field is for validation purposes and should be left unchanged. Please do not submit any Protected Health Information (PHI).
