Neurotransmitter

Part I - Please check the appropriate number “0-3” on all questions below. 0 as the least/never to 3 as the most/always.

SECTION A

(Least/Never)  01 23  (Most/Always)

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

SECTION B

(Least/Never)  01 23  (Most/Always)

• How is your stress level?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel that you have something that must be done?
  • 0
  • 1
  • 2
  • 3
    
• Do you feel you never have time for yourself?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel you are not getting enough sleep or rest?
  • 0
  • 1
  • 2
  • 3
    
• Do you find it difficulty to get regular exercise ?
  • 0
  • 1
  • 2
  • 3
    
• Do you feel uncared for by the people in your life?
  • 0
  • 1
  • 2
  • 3
    
• Do you feel you are not accomplishing your life’s purpose?
  • 0
  • 1
  • 2
  • 3
    
• Is sharing your problems with someone difficult for you?
  • 0
  • 1
  • 2
  • 3
    

SECTION C-1

(Least/Never)  01 23  (Most/Always)

• How often do you get irritable, shaky, or have lightheadedness between meals?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel energized after eating?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have difficulty eating large meals in the morning?
  • 0
  • 1
  • 2
  • 3
    
• How often does your energy level drop in the afternoon?
  • 0
  • 1
  • 2
  • 3
    
• How often do crave sugar and sweet in the afternoon?
  • 0
  • 1
  • 2
  • 3
    
• How often do you wake up in the middle of the night?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have difficulty concentrating before eating?
  • 0
  • 1
  • 2
  • 3
    
• How often do you depend on coffee to keep yourself going?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel agitated ,easily upset, and nervous between meals?
  • 0
  • 1
  • 2
  • 3
    

SECTION C-2

(Least/Never)  01 23  (Most/Always)

• Do you get fatigued after meals?
  • 0
  • 1
  • 2
  • 3
    
• Do you crave sugar and sweets after meals?
  • 0
  • 1
  • 2
  • 3
    
• Do you feel you need stimulants such as coffee after meals?
  • 0
  • 1
  • 2
  • 3
    
• Do you have difficulty losing weight?
  • 0
  • 1
  • 2
  • 3
    
• How much larger your waist girth compared to your hip girth?
  • 0
  • 1
  • 2
  • 3
    
• How often do you urinate?
  • 0
  • 1
  • 2
  • 3
    
• Have your thirst and appetite been increased?
  • 0
  • 1
  • 2
  • 3
    
• Do you have weight gain when under stress?
  • 0
  • 1
  • 2
  • 3
    
• Do you have difficulty falling asleep?
  • 0
  • 1
  • 2
  • 3
    

SECTION S-1

(Least/Never)  01 23  (Most/Always)

• Are you losing your pleasure in hobbies and interest?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel overwhelmed with ideas to manage?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have feelings of inner rage (anger)?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have feeling of paranoia?
  • 0
  • 1
  • 2
  • 3
    
• How often do feel sad or down for no reason?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel like you are not enjoying life?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel you lack artistic appreciation?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel depressed in overcast weather?
  • 0
  • 1
  • 2
  • 3
    
• How much are you loosing enjoyment for your favorite foods?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have difficulty falling into deep restful sleep?
  • 0
  • 1
  • 2
  • 3
    
• How much are you losing your enthusiasm for your favorite activities?
  • 0
  • 1
  • 2
  • 3
    
• How much are you losing your enjoyment of friendship and relationship?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have difficulty falling of dependency on other?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel more susceptible to pain?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have feeling of unprovoked anger?
  • 0
  • 1
  • 2
  • 3
    
• How much are you losing interest in life?
  • 0
  • 1
  • 2
  • 3
    

SECTION 2-D

(Least/Never)  01 23  (Most/Always)

• How often do you have feelings of hopelessness?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have self-destructive thoughts?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have an inability to handle stress?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have anger and aggression while under stress?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel you are not rested even after long hours of sleep?
  • 0
  • 1
  • 2
  • 3
    
• How often do you prefer to isolate yourself from others?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have unexplained lack of concern for family and friends?
  • 0
  • 1
  • 2
  • 3
    
• How easily are you distracted from your tasks?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have an inability to finish tasks?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel the need to consume caffeine to stay alert?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel your libido has been decreased?
  • 0
  • 1
  • 2
  • 3
    
• How often do you lose your temper for minor reasons?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have feelings of worthlessness?
  • 0
  • 1
  • 2
  • 3
    

SECTION 3-G

(Least/Never)  01 23  (Most/Always)

• How often do you feel anxious or panic for no reason?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have feelings of dread or impending doom?
  • 0
  • 1
  • 2
  • 3
    
• How often do you feel knots in your stomach?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have feelings of being overwhelmed for no reason?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have feelings of guilt about everyday decisions?
  • 0
  • 1
  • 2
  • 3
    
• How often does your mind feel restless?
  • 0
  • 1
  • 2
  • 3
    
• How difficult is it to turn your mind off when you want to relax?
  • 0
  • 1
  • 2
  • 3
    
• How often do you worry about things you were not worried about before?
  • 0
  • 1
  • 2
  • 3
    
• How often do you have feelings of inner tension and inner excitability?
  • 0
  • 1
  • 2
  • 3
    

SECTION 4-ACH

(Least/Never)  01 23  (Most/Always)

• Do you feel your visual memory (shapes & images) is decreased?
  • 0
  • 1
  • 2
  • 3
    
• Do you feel your verbal memory is decreased?
  • 0
  • 1
  • 2
  • 3
    
• Do you have memory lapses?
  • 0
  • 1
  • 2
  • 3
    
• Has your creativity been decreased?
  • 0
  • 1
  • 2
  • 3
    
• Has your comprehension been diminished?
  • 0
  • 1
  • 2
  • 3
    
• Do you have difficulty calculating numbers?
  • 0
  • 1
  • 2
  • 3
    
• Do you have difficulty recognizing objects & faces?
  • 0
  • 1
  • 2
  • 3
    
• Do you feel like your opinion about yourself has changed?
  • 0
  • 1
  • 2
  • 3
    
• Are you experiencing excessive urination?
  • 0
  • 1
  • 2
  • 3
    
• Are you experiencing slower mental response?
  • 0
  • 1
  • 2
  • 3