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["Neurotransmitter Assessment Form"]
[]
["Name: ","Date: "]
[]
["Score each question 0 to 3.   0 = least/never, 3 = most/always"]
[]
["Section A"]
["Is your memory noticably declining?"]
["Are you having a hard time remembering names and phone numbers?"]
["Is your ability to focus noticably declining?"]
["Has it become harder for you to learn things?"]
["Do you have a hard time remembering your appointments?"]
["Is your temperament getting worse in general?"]
["Are you losing your attention span endurance?"]
["Are you more depressed than usual?"]
["Do you fatigue when driving sooner than in the past?"]
["Do you fatigue when reading sooner than in the past?"]
["Do you walk into rooms and forget why?"]
["Do you pick up the phone and forget why?"]
["Section A Total:",{"$f":"SUM(B8:B19)","v":0}]
[]
["Section B"]
["Is your stress level high?"]
["Do you always have something that must be done?"]
["Do you feel you never have time for yourself?"]
["Do you feel you are not getting enough sleep or rest?"]
["Are you not getting enough regular exercise?"]
["Do you feel that you are not cared about enough by others?"]
["Do you feel that you are not accomplishing your life's purpose?"]
["Do you feel there is nobody to share your problems with?"]
["Section B Total:",{"$f":"SUM(B23:B30)","v":0}]
[]
["Section C"]
["Section C1"]
["Do you get irritable, shaky, or light-headed between meals?"]
["Do you feel energized after eating?"]
["Do you have difficulty eating large meals in the morning?"]
["Does your energy level drop in the afternoon?"]
["Do you crave sugar or sweets in the afternoon?"]
["Do you wake up in the middle of the night?"]
["Do you have difficulty concentrating before eating?"]
["Do you depend on coffee to keep yourself going?"]
["Do you feel agitated, easily upset, or nervous between meals?"]
["Section C1 Subtotal:",{"$f":"SUM(B35:B43)","v":0}]
["Section C2"]
["Do you get fatigued or sleepy after meals?"]
["Do you crave sugar or sweets after meals?"]
["Do you feel the need for stimulants such as coffee after meals?"]
["Do you have difficulty losing weight?"]
["Is your waist circumference equal to or larger than your hip circumference?"]
["Do you have frequent urination?"]
["Has your thirst and appetite increased?"]
["Do you still crave sugar after eating sweets?"]
["Do you have weight gain when under stress?"]
["Do you have difficulty falling asleep?"]
["Section C2 Subtotal:",{"$f":"SUM(B46:B55)","v":0}]
["Section C Total:",{"$f":"SUM(B44,B56)","v":0}]
[]
["Section 1"]
["Are you losing pleasure in interests and hobbies?"]
["Do you feel overwhelmed with ideas to manage?"]
["Do you have feelings of inner rage (anger)?"]
["Do you have feelings of paranoia?"]
["Do you feel depressed?"]
["In general, do you feel you are not enjoying life?"]
["Do you feel you lack artistic appreciation?"]
["Do you feel depressed in overcast weather?"]
["Are you losing enthusiasm for your favorite activities?"]
["Are you losing enjoyment for your favorite foods?"]
["Are you losing enjoyment of friendships and relationships?"]
["Do you have difficulty falling into deep restful sleep?"]
["Do you feel dependent on others?"]
["Do you feel more susceptible to pain?"]
["Do you have feelings of unprovoked anger?"]
["Are you losing interest in life?"]
["Section 1 Total:",{"$f":"SUM(B60:B75)","v":0}]
[]
["Section 2"]
["Do you have feelings of hopelessness?"]
["Do you have self-destructive thoughts?"]
["Do you have an inability to handle stress?"]
["Do you have anger and aggression while under stress?"]
["Do you feel you are not rested even after long hours of sleep?"]
["Do you prefer to isolate yourself from others?"]
["Do you have unexplained lack of concern for family and friends?"]
["Are you distracted easily?"]
["Do you have an inability to finish tasks?"]
["Do you feel the need to consume caffeine to stay alert?"]
["Do you feel your libido has been decreased?"]
["Do you lose your temper for minor reasons?"]
["Do you have feeling of worthlessness?"]
["Section 2 Total:",{"$f":"SUM(B79:B91)","v":0}]
[]
["Section 3"]
["Do you feel anxious or panic for no reason?"]
["Do you have feelings of dread, or pending gloom?"]
["Do you feel knots in you stomach?"]
["Do you have feelings of being overwhelmed for no reason?"]
["Do you have feelings of guilt about everyday decisions?"]
["Does your mind feel restless?"]
["Is it difficult to turn your mind off when you want to relax?"]
["Do you have disorganized attention?"]
["Do you now worry about things you were not worried about before?"]
["Do you have feelings of inner tension and inner excitability?"]
["Section 3 Total:",{"$f":"SUM(B95:B104)","v":0}]
[]
["Section 4"]
["Do you feel your visual memory (shapes & images) is decreased?"]
["Do you feel your verbal memory is decreased?"]
["Do you have memory lapses?"]
["Has your creativity been 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 is changed?"]
["Are you experiencing excessive urination?"]
["Are you experiencing a slower mental response?"]
["Section 4 Total:",{"$f":"SUM(B108:B117)","v":0}]

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