Form – Neurotransmitter Assessment Form

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 A

Low brain endurance for focus and concentration
Cold hands and feet
Must exercise or drink coffee to improve brain function
Poor nail health
Fungal growth on toe nails
Must wear socks at night
Nail beds are white instead of pink
The tip of the nose is cold
The tip of the nose is cold
The tip of the nose is cold
The tip of the nose is cold
The tip of the nose is cold

SECTION B

Irritable, nervous, shaky, or light-headed between meals
Feel energized after meals
Difficulty eating large meals in the morning
Energy level drops in the afternoon
Crave sugar and sweets in the afternoon
Wake up in the middle of the night
Difficulty concentrating before eating
Depend on coffee to keep going

SECTION C

SECTION C1

Fatigue after meals
Sugar and sweet cravings after meals
Need for a stimulant, such as coffee, after meals
Difficulty losing weight
Increased frequency of urination
Difficulty falling asleep
Increased appetite
Increased appetite
Increased appetite

SECTION C2

Increased appetite
Increased appetite
Increased appetite
Increased appetite
Increased appetite
Increased appetite
Increased appetite
Increased appetite
Increased appetite

SECTION 1

Always have projects and things that need to be done
Never have time for yourself
Not getting enough sleep or rest
Difficulty getting regular exercise
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose
Feel that you are not accomplishing your life’s purpose

SECTION 2

Dry and unhealthy skin
Dandruff or a flaky scalp
Consumption of processed foods that are bagged or boxed
Consumption of fried foods
Difficulty consuming raw nuts or seeds
Difficulty consuming fish (not fried)
Difficulty consuming olive oil, avocados, flax seed oil, or natural fats
Difficulty consuming olive oil, avocados, flax seed oil, or natural fats
Difficulty consuming olive oil, avocados, flax seed oil, or natural fats
Difficulty consuming olive oil, avocados, flax seed oil, or natural fats
Difficulty consuming olive oil, avocados, flax seed oil, or natural fats
Difficulty consuming olive oil, avocados, flax seed oil, or natural fats
Difficulty consuming olive oil, avocados, flax seed oil, or natural fats

SECTION 3

Difficulty digesting foods
Constipation or inconsistent bowel movements
Increased bloating or gas
Abdominal distention after meals
Decisions made based on desires, regardless of the consequences
Difficulty digesting protein-rich foods
Difficulty digesting starch-rich foods
Difficulty digesting fatty or greasy foods
Difficulty swallowing supplements or large bites of food
Difficulty swallowing supplements or large bites of food

SECTION 4

Brain fatigue after meals
Brain fatigue after exposure to chemicals, scents, or pollutants
Brain fatigue when the body is inflamed
Brain fatigue when the body is inflamed
Brain fatigue when the body is inflamed
Brain fatigue when the body is inflamed
Brain fatigue when the body is inflamed
Brain fatigue when the body is inflamed
Brain fatigue when the body is inflamed
Brain fatigue when the body is inflamed

Medication History*

Please check any of the following medications you have taken in the past or are currently taking.

Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas)
This field is for validation purposes and should be left unchanged.

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