neurotransmitter assessment form

celilo natural health center: neurotransmitter assessment form

this questionnaire helps us determine which systems may be affecting your mood
your name*

First NameLast Name
your birth date

MonthDayYear
today's date

MonthDayYear
your address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
your email, if we may use this
best phone number to reach you

Area CodePhone Number

Rows	0	1	2	3
Is your memory noticeably declining?
Are you having a hard time remembering names and phone numbers?
Is your ability to focus noticeably declining?
Has it become harder for you to learn things?
How often do you have a hard time remembering your appointments?
Is your temperament getting worse in general?
Are you losing your attention-span endurance?
How often do you find yourself down or sad?
How often do you fatigue when driving compared to the past?
How often do you fatigue when reading compared to the past?
How often do you walk into rooms and forget why?
How often do you pick up your phone and forget why?

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How high is your stress level?
How often do you feel that you have something that must be done?
Do you feel you never have time for yourself?
How often do you feel you are not getting enough rest or sleep?
Do you find it difficult to get regular exercise?
Do you feel uncared for by the people in your life?
Do you feel your are not accomplishing your life's purpose?
Is sharing your problems with someone difficult for you?

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How often do you get irritabe, shaky or feel lightheaded between meals?
How often do you feel energized after eating?
How often do you have difficulty eating large meals in the morning?
How often does your energy level drop in the afternoon?
How often do you crave sugar and sweets in the afternoon?
How often do you wake up in the middle of the night?
How often do you have difficulty concentrating before eating?
How often do you depend on coffee to keep yourself going?
How often do you feel agitated, easily upset and nervous between meals?

Do you get fatigued after meals?
Do you crave sugar and sweets after meals?
Do you feel you need stimulants such as coffee after meals?
Do you have difficulty losing weight?
How much larger is your waist girth compared to your hip girth:
How often do you urinate?
Have your thirst and appetite been increased?
Do you gain weight when under stress?
Do you have difficulty falling asleep?

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Are you losing your pleasure in hobbies and interests?
How often do you feel overwhelmed with ideas to manage?
How often do you have feelings of inner rage (anger)?
How often do you have feelings of paranoia?
How often do you feel sad or down for no reason?
How often do you feel that you are not enjoying life?
How often do you feel you lack artistic appreciation?
How often do you feel depressed in overcast weather?
How much are you losing your enthusiasm for your favorite activities?
How much are you losing your enjoyment of friends and relationships?
How often do you have difficulty falling into deep, restful sleep?
How often do you have feelings of dependency on others?
How often do you feel more susceptible to pain?
How often do you have feelings of unprovoked anger?
How much are you losing interest in life?

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How often do you have feelings of hopelessness?
How often do you have self-destructive thoughts?
How often do you have an inability to handle stress?
How often do you have anger and aggression while under stress?
How often do you feel you are not rested even after long hours of sleep?
How often do you prefer to isolate yourself from others?
How often do you have unexplained lack of concern for family and friends?
How easily are you distracted from your tasks?
How often do you have an inability to finish tasks?
How often do you feel the need to consume caffeine to stay alert?
How often do you feel your libido has been decreased?
How often do you lose your anger for minor reasons?
How often do you have feelings of worthlessness?

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How often do you feel anxious or panic for no reasons?
How often do you have feelings of dread or impending doom?
How often do you feel knots in your stomach?
How often do you have feelings of being overwhelmed for no reason?
How often do you have feelings of guilt about everyday decisions?
How often does your mind feel restless?
How difficult is it to turn your mind off when you want to relax?
How often do you have disorganized attention?
How often do you worry about things you were not worried about before?
How often do you have feelings of inner tension and inner excitability?

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Do you feel your visual memory (shapes and images) is decreased?
Do you feel your verbal memory is decreased?
Do you have memory lapses?
Has your creativity decreased?
Has your comprehension been diminished?
Do you have difficulty calculating numbers?
Do you have difficulty recognizing objects and faces?
Do you feel your opinion about yourself has changed?
Are you experiencing excessive urination?
Are you experiencing slower mental response?

celilo natural health center: neurotransmitter assessment form