Child Neurotransmitter and Nutrition

Please check the appropriate number “0-3” on all questions below. 0 as the least/never to 3 as the most/always, unless otherwise specified in the question.

SECTION A

(Least/Never)  01 23  (Most/Always)

• Does your child eat pasta, breads, and breaded foods?
  • 0
  • 1
  • 2
  • 3
    
• Does your child have symptoms (fatigue, hyperactivity, etc.)
  after eating wheat foods?
  • 0
  • 1
  • 2
  • 3
    
• Does your child eat dairy products?
  • 0
  • 1
  • 2
  • 3
    
• Does your child have symptoms (fatigue, hyperactivity, etc.)
  after eating dairy products?
  • 0
  • 1
  • 2
  • 3
    

SECTION: B

(Least/Never)  01 23  (Most/Always)

• Is 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 : D

(Least/Never)  01 23  (Most/Always)

• Does your child have stress?
  • 0
  • 1
  • 2
  • 3
    
• Does your child not have enough sleep and rest?
  (mark “3” if not enough rest)
  • 0
  • 1
  • 2
  • 3
    
• Does your child not have regular exercise?
  (mark “3” if no exercise)
  • 0
  • 1
  • 2
  • 3
    
• Does your child feel overly worried and scared?
  • 0
  • 1
  • 2
  • 3
    

SECTION : E

(Least/Never)  01 23  (Most/Always)

• Does 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?
  (mark “3” if unable)
  • 0
  • 1
  • 2
  • 3
    
• 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 when it is inappropriate?
  • 0
  • 1
  • 2
  • 3
    
• Does your child have difficulty playing quietly or engaging in leisure activities?
  • 0
  • 1
  • 2
  • 3
    

SECTION : F

(Least/Never)  01 23  (Most/Always)

• Does your child get excited easily?
  • 0
  • 1
  • 2
  • 3
    
• Does your child have anxiousness 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 she/he is awake?
  • 0
  • 1
  • 2
  • 3
    
• Does your child have disorganized attention?
  • 0
  • 1
  • 2
  • 3
    

SECTION: G

(Least/Never)  01 23  (Most/Always)

• Does 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 symptoms of unprovoked anger?
  • 0
  • 1
  • 2
  • 3
    
• Does your child seem uninterested in eating?
  • 0
  • 1
  • 2
  • 3
    

SECTION: H

(Least/Never)  01 23  (Most/Always)

• Does 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 long sleeps?
  • 0
  • 1
  • 2
  • 3
    
• Does your child tend to isolate from others?
  • 0
  • 1
  • 2
  • 3
    
• Does your child get distracted easily?
  • 0
  • 1
  • 2
  • 3
    
• Does your child have constant need and desire for candy and sugar?
  • 0
  • 1
  • 2
  • 3
    
• Does your child have disorganized attention?
  • 0
  • 1
  • 2
  • 3
    

SECTION: I

(Least/Never)  01 23  (Most/Always)

• Does your child have difficulty with visual memory?
  • 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 low attention span or endurance?
  • 0
  • 1
  • 2
  • 3
    
• Does your child have slow or difficult speech?
  • 0
  • 1
  • 2
  • 3
    
• Does your child have uncoordinated or slow movement?
  • 0
  • 1
  • 2
  • 3