Form – Neurotransmitter Assessment Form Name(Required) Age: Sex Date 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 ALow brain endurance for focus and concentration 0 1 2 3 Cold hands and feet 0 1 2 3 Must exercise or drink coffee to improve brain function 0 1 2 3 Poor nail health 0 1 2 3 Fungal growth on toe nails 0 1 2 3 Must wear socks at night 0 1 2 3 Nail beds are white instead of pink 0 1 2 3 The tip of the nose is cold 0 1 2 3 The tip of the nose is cold 0 1 2 3 The tip of the nose is cold 0 1 2 3 The tip of the nose is cold 0 1 2 3 The tip of the nose is cold 0 1 2 3 SECTION BIrritable, nervous, shaky, or light-headed between meals 0 1 2 3 Feel energized after meals 0 1 2 3 Difficulty eating large meals in the morning 0 1 2 3 Energy level drops in the afternoon 0 1 2 3 Crave sugar and sweets in the afternoon 0 1 2 3 Wake up in the middle of the night 0 1 2 3 Difficulty concentrating before eating 0 1 2 3 Depend on coffee to keep going 0 1 2 3 SECTION CSECTION C1Fatigue after meals 0 1 2 3 Sugar and sweet cravings after meals 0 1 2 3 Need for a stimulant, such as coffee, after meals 0 1 2 3 Difficulty losing weight 0 1 2 3 Increased frequency of urination 0 1 2 3 Difficulty falling asleep 0 1 2 3 Increased appetite 0 1 2 3 Increased appetite 0 1 2 3 Increased appetite 0 1 2 3 SECTION C2Increased appetite 0 1 2 3 Increased appetite 0 1 2 3 Increased appetite 0 1 2 3 Increased appetite 0 1 2 3 Increased appetite 0 1 2 3 Increased appetite 0 1 2 3 Increased appetite 0 1 2 3 Increased appetite 0 1 2 3 Increased appetite 0 1 2 3 SECTION 1Always have projects and things that need to be done 0 1 2 3 Never have time for yourself 0 1 2 3 Not getting enough sleep or rest 0 1 2 3 Difficulty getting regular exercise 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 Feel that you are not accomplishing your life’s purpose 0 1 2 3 SECTION 2Dry and unhealthy skin 0 1 2 3 Dandruff or a flaky scalp 0 1 2 3 Consumption of processed foods that are bagged or boxed 0 1 2 3 Consumption of fried foods 0 1 2 3 Difficulty consuming raw nuts or seeds 0 1 2 3 Difficulty consuming fish (not fried) 0 1 2 3 Difficulty consuming olive oil, avocados, flax seed oil, or natural fats 0 1 2 3 Difficulty consuming olive oil, avocados, flax seed oil, or natural fats 0 1 2 3 Difficulty consuming olive oil, avocados, flax seed oil, or natural fats 0 1 2 3 Difficulty consuming olive oil, avocados, flax seed oil, or natural fats 0 1 2 3 Difficulty consuming olive oil, avocados, flax seed oil, or natural fats 0 1 2 3 Difficulty consuming olive oil, avocados, flax seed oil, or natural fats 0 1 2 3 Difficulty consuming olive oil, avocados, flax seed oil, or natural fats 0 1 2 3 SECTION 3Difficulty digesting foods 0 1 2 3 Constipation or inconsistent bowel movements 0 1 2 3 Increased bloating or gas 0 1 2 3 Abdominal distention after meals 0 1 2 3 Decisions made based on desires, regardless of the consequences 0 1 2 3 Difficulty digesting protein-rich foods 0 1 2 3 Difficulty digesting starch-rich foods 0 1 2 3 Difficulty digesting fatty or greasy foods 0 1 2 3 Difficulty swallowing supplements or large bites of food 0 1 2 3 Difficulty swallowing supplements or large bites of food 0 1 2 3 SECTION 4Brain fatigue after meals 0 1 2 3 Brain fatigue after exposure to chemicals, scents, or pollutants 0 1 2 3 Brain fatigue when the body is inflamed 0 1 2 3 Brain fatigue when the body is inflamed 0 1 2 3 Brain fatigue when the body is inflamed 0 1 2 3 Brain fatigue when the body is inflamed 0 1 2 3 Brain fatigue when the body is inflamed 0 1 2 3 Brain fatigue when the body is inflamed 0 1 2 3 Brain fatigue when the body is inflamed 0 1 2 3 Brain fatigue when the body is inflamed 0 1 2 3 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) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® Noradrenergic and Specific Sertonergic Monoamine Oxidase Inhibitors (MAOIs) Antidepressants (NaSSAas) Remeron® Zispin® Avanza® Norset® Remergil® Axit® CAPTCHACommentsThis field is for validation purposes and should be left unchanged. 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