Neurotransmitter Assessment Form

Please fill out this neurotransmitter assessment form, the patient intake form, the wellness evaluation form, and the metabolic assessment form. Be sure to submit them before your wellness consultation, so Dr. Dae can review them and create a wellness plan for you.

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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 new things?

How often do you have a hard time remembering your appointments?

Is your temperament generally getting worse?

Is your attention span decreasing?

How often do you find yourself down or sad?

How often do you become fatigued when driving compared to in the past?

How often do you become fatigued when reading compared to in the past?

How often do you walk into rooms and forget why? (r

How often do you pick up your cell phone and forget why?

How high is your stress level?

How often do you feel 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 sleep or rest?

Do you find it difficult to get regular exercise?

Do you feel uncared for by the people in your life?

Do you feel you are not accomplishing your life’s purpose?

Is sharing your problems with someone difficult for you?

How often do you get irritable, shaky, or have light-headedness 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?

How often do you get fatigued after meals?

How often do you crave sugar and sweets after meals?

How often do you feel you need stimulants, such as coffee, after meals?

How often 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 increased?

How often do you gain weight when under stress?

How often do you have difficulty falling asleep?

Are you losing interest in hobbies?

How often do you feel overwhelmed?

How often do you have feelings of inner rage?

How often do you have feelings of paranoia?

How often do you feel sad or down for no reason?

How often do you feel like 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 for your favorite foods?

How much are you losing your enjoyment of friendships 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?

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 friends and family?

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 temper for minor reasons?

How often do you have feelings of worthlessness?

How often do you feel anxious or panicked for no reason?

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?

Do you feel your visual memory (shapes & images) has decreased?

Do you feel your verbal memory has decreased?

Do you have memory lapses?

Has your creativity decreased?

Has your comprehension diminished?

Do you have difficulty calculating numbers?

Do you have difficulty recognizing objects & faces?

Do you feel like your opinion about yourself has changed?

Are you experiencing excessive urination?

Are you experiencing a slower mental response?

Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

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

Noradrenergic and Specific Sertonergic Antidepressants (NaSSAas)

Tricylic Antidepressants (TCAs)

Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Selective Serotonin Reuptake Enhancers (SSREs)

Stablon®

Coaxil®

Tatinol®

None of the above

Monoamine Oxidase Inhibitors (MAOIs)

Dopamine Receptor Agonists

Mirapex®

Sifrol®

Requip®

None of the above

Norepinephrine and Dopamine Reuptake Inhibitors (NDRI)

Wellbutrin XL®

None of the above

D2 Dopamine Receptor Blockers (antipsychotics)

GABA Antagonist Competitive Binder

Romazicon®

None of the above

Agonist Modulators of GABA Receptors (benzodiazepines)

Agonist Modulators of GABA Receptors (non-benzodiazepines)

Acetylcholine Receptor Agonists

Acetylcholine Receptor Antagonists Antimuscarinic Agents

Acetylcholine Receptor Antagonists Ganglionic Blockers

Acetylcholine Receptor Antagonists Neuromuscular Blockers

Acetylcholinesterase Reactivators

Protopam®

None of the above

Cholinesterase Inhibitors (reversible)

Cholinesterase Inhibitors (irreversible)

*Please refer to prescribing physician for nutritional interactions with any medications you are taking