INTAKE QUESTIONNAIRE FOR ADULTS

Full Name Occupation

Home Address Company

City State Zip Date of Birth Gender M F

Emergency Contact Relationship Phone

Phone (home) (work) (cell) Email

Whom may we thank for referring you? Social Security #

I, , understand that I am personally responsible for payment at the time when services are rendered.

Signature Date

If you know which services you are interested in, please check all that apply:

I have an issue I would like to address through the use of Cryotherapy or Whole Body Photobiomodulation without consultation with the doctor. **you may skip to page 12

Childhood Development and Learning Functional Neurology Assessment (request Childhood Development intake form)

I do not know what I need, but I would like to find out! (continue below)

I have no current health issues, but would like preventative / wellness care (continue below-if under the age of 15 please request the pediatric intake form)

Whole Body Cryotherapy

Whole Body Photobiomodulation

Laser Therapy

Clinical Nutrition Chiropractic Care Massage

Childhood Development & Learning Functional Neurology

1

PRIMARY CONCERN

What is your primary health problem? ___________________________________________________________

_____________________________________________________________________________________________

Date of original problem: __________________________ Date of most recent recurrence: _______________

Was there an event that created the problem? ____________________________________________________

Have you had this or similar conditions in the past? ________ Is the problem worsening? ______________

What makes it better? _________________________________________ Worse? ________________________

Is the problem interfering with work? __________ Sleep? __________ Activity? ________ Other?_________

What can you not do now that you would like to do? ______________________________________________

What do you believe is wrong with you? _________________________________________________________

_____________________________________________________________________________________________

What are your goals for treatment? ______________________________________________________________

HEALTH HISTORYList all other CURRENT problems in their order of importance ____________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

List other practitioners seen, treatments, self care activities, and results _____________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Have you ever seen a chiropractor? No / Yes (Name: ____________________ Result:_________________)

Do you have any spinal abnormalities that you are aware of? _______________________________________

List ALL significant PAST illnesses ______________________________________________________________

2

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please list ALL surgeries you have had, with approximate dates and results __________________________

_____________________________________________________________________________________________

Have you ever been hospitalized other than for surgery? ___________________________________________

Have you ever been in an accident or seriously injured? List dates and describe______________________

_____________________________________________________________________________________________

Have you ever had: Whiplash? No / Yes Hard fall on your tailbone? No / Yes Seizure? No / Yes

Describe your worst injury ever, and any long lasting effects it has had on your health _________________

_____________________________________________________________________________________________

Describe any travel related illnesses _____________________________________________________________

How many doses of antibiotics have you had in your lifetime?__________________________________________

How many times per month do you take aspirin? ____ Ibuprofen? ____ Tylenol? ____ Antacids? ____ Laxatives? ____

For what purpose do you take these? ___________________________________________________________

FAMILY HISTORYHave any of your blood relatives (parents, brothers, sisters, aunts, uncles, grandparents, or children), living or deceased, had any of the following problems? For each YES, state the age of the person when the problem occurred and their relationship with you.

Condition Yes No Age Relationship

Alcoholism/Drug Addiction

Allergies/Asthma

Arthritis

Blood Disorders

Cancer (typ )

Diabetes

Digestive Disorders (type )

Heart attack before age 55

3

List other problems that run in your family _______________________________________________________

HABITS

Describe your use of cigarettes/tobacco _______________ Alcohol ________________ Other drugs ______

Describe your exercise habits (activity/times per week/intensity) ____________________________________

Describe your current sleeping pattern (when you usually go to sleep, wake up, napping, difficulty with

sleep) _______________________________________________________________________________________

Do you have enough energy for your normal activities? No / Yes

PREVENTIVE MEASURES AND SCREENING

Have you ever had an MRI or CT scan? No / Yes If so, what for? ________________________________

Have you ever had x-rays? No / Yes If so, what for? __________________________________________

Have you ever had an EKG or other heart study? No / Yes If so, what for? _________________________

Please list any abnormal labs or other test results: (OK to attach copies instead) ______________________

Heart attack before after age 55

High blood pressure

Kidney or Liver disease

Lung disease/tuberculosis

Mental health problems/depression

Seizure Disorder

Stroke

Thyroid Disease

Uterine/Ovarian problems

Have any of your blood relatives (parents, brothers, sisters, aunts, uncles, grandparents, or children), living or deceased, had any of the following problems? For each YES, state the age of the person when the problem occurred and their relationship with you.

4

Y N AGE

ALLERGIES AND SENSITIVITIES

Please list any allergies you are aware of (foods/medications/other): ________________________________

Please list any chemical sensitivities you are aware of: (bleach, solvents, perfumes, etc.) ________________________

Are you particularly sensitive to the effects of alcohol or medications? No / Yes

Have you ever reacted to a medication in an unexpected way (for example, feeling more calm if you took

a stimulant)? No / Yes If yes, please describe ______________________________________________

Have you had problems with damp or moldy places? No / Yes Problems with new building materials? No / Yes

NUTRITION

What do you usually eat and drink on a typical weekday?

Breakfast ________________________________________________________________________

Morning snack ________________________________________________________________________

Lunch ________________________________________________________________________

Afternoon snack _______________________________________________________________________

Dinner ________________________________________________________________________

Evening snack ________________________________________________________________________

Desserts ________________________________________________________________________

How many glasses of water do you drink a day? _______________________________________________________________________

How many servings do you have per day of the following:

Fruits & Vegetables ______ Coffee ______ Tea ______ Soda ______ Diet Soda ______

List the oils or fats you use in the cooking/preparing of food: _______________________________________

Do you enjoy eating cheese? No / Yes Do you drink milk? No / Yes If so, how much per day? ________

Do you like sweets, pastries, cakes, donuts, etc? No / Yes How many servings per day?____________

Do you consume artificial sweeteners with coffee and food? No / Yes How many servings per day?

When you have a snack, what type of food do you prefer? _________________________________________

Is there one food that you like the most, eat a lot of, and crave when you don’t have it? _______________

Are there days you do not eat any vegetables? No / Yes

5

What foods do you especially like? ______________________________________________________________

What foods do you dislike? ____________________________________________________________________

Are there particular foods that seem to irritate you in any way? No / Yes If yes, name the foods and

describe the problem: _________________________________________________________________________

Please describe any ways in which you feel your diet is excessive: __________________________________

_____________________________________________________________________________________________

Please describe any ways in which you feel your diet is deficient: ___________________________________

_____________________________________________________________________________________________

List all hormones that you take now or have taken in the past. Please indicate form (pill, cream, injection etc.)

_____________________________________________________________________________________________

MEDICATIONSThe treatment that the Doctors provide is intended to improve all aspects of your health. As your care progresses, your body may be better able to heal itself in all respects. Because of this, your blood pressure, blood sugar levels, blood clotting characteristics, and other important bodily functions may improve. If this occurs, it is possible that the doses of medications you are taking will have to be modified, to account for your improvement. It is your responsibility to monitor or have monitored those functions that relate to medications you are currently taking, to ensure that your current dose does not become excessive or deficient in its effect on you. These and any other changes to your regimen of medications must be made in coordination with, and under the instructions of, the physician who prescribed them.

Please list the names of medications you are currently taking as well as the reason for them.

________________________________________ ________________________________________

________________________________________ ________________________________________

________________________________________ ________________________________________

________________________________________ ________________________________________

________________________________________ ________________________________________

________________________________________ ________________________________________

6

Please list the names of supplements you are currently taking and reason for them.

________________________________________ ________________________________________

________________________________________ ________________________________________

________________________________________ ________________________________________

________________________________________ ________________________________________

________________________________________ ________________________________________

________________________________________ ________________________________________

ADDITIONAL INFORMATIONPlease arrange to have any other relevant information sent to our office. This might include medical records, lab results, consultation reports, and any other test or study results such as x-rays or CT scans. This will help the doctors evaluate your condition. Short documents like lab results or MRI reports may be faxed to (919) 759-9188. Longer documents like overall patient records should be copied and sent to the office at 206 E. Mulberry St., Goldsboro, NC 27530.

Please list the names of your primary care doctor, gynecologist (if applicable), and/or other doctors, so the doctors can send a report to them with the details of his findings in your case, should it become appropriate for him to do so. List each doctor’s full name and as much of the address information as you know.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

7

To the best of your knowledge, the detailed information that you have provided is accurate, and allows the doctors a more thorough understanding of you and your health concerns. Sharing these details helps you receive the highest quality care we are capable of providing.

If you would like to add any further information that you feel would be helpful to the doctors understanding of your condition, please attach a typed page and return along with this material.

Signature ____________________________________________ Date ___________________

FINANCIAL OFFICE POLICYPatient Care Services.We require that charges on the date of service be paid in full, except If you have a documented worker’s compensation case or accident with all appropriate forms and liens signed. We do reserve the right to charge 1.5 percent monthly interest on all account balances over 60 days.

Our Policy on Health Insurance. Today most policies do cover alternative health care however there is a large number that have copays that are much greater than our fees, therefore we will not submit those claims. We cannot take responsibility for what your health insurance will or will not cover.

Appointments.In order to better serve our patients, we ask that you call in advance if you are unable to make your appointment, or if you will be late. Your appointment time is reserved especially for you. If you fail to notify our office, it leaves an appointment time that could have been used by someone in need. Please help us help others. Questions and Answers.Please feel free to ask any available staff member questions regarding your account. We will make every effort to answer your inquiries.

Signature ____________________________________________ Date ___________________

8

Name: ___________________________________________ Age: ______ Sex: _____ Date: ____________________

PART I

Please list your 5 major health concerns in order of importance:

1. ____________________________________________ 4. ___________________________________________ 2. ____________________________________________ 5. ___________________________________________3. ____________________________________________

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

Metabolic Assessment Formtm

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

Category I Feeling that bowels do not empty completely Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or “fuzzy” debris on tongue Pass large amount of foul-smelling gasMore than 3 bowel movements daily Use laxatives frequently

Category II Increasing frequency of food reactions Unpredictable food reactions Aches, pains, and swelling throughout the body Unpredictable abdominal swellingFrequent bloating and distention after eating Category III Intolerance to smellsIntolerance to jewelryIntolerance to shampoo, lotion, detergents, etcMultiple smell and chemical sensitivitiesConstant skin outbreaks Category IV Excessive belching, burping, or bloatingGas immediately following a mealOffensive breathDifficult bowel movementsSense of fullness during and after mealsDifficulty digesting proteins and meats; undigested food found in stools

Category VStomach pain, burning, or aching 1-4 hours after eatingUse of antacidsFeel hungry an hour or two after eatingHeartburn when lying down or bending forwardTemporary relief by using antacids, food, milk, or carbonated beveragesDigestive problems subside with rest and relaxationHeartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Category VI Difficulty digesting roughage and fiberIndigestion and fullness last 2-4 hours after eatingPain, tenderness, soreness on left side under rib cageExcessive passage of gasNausea and/or vomitingStool undigested, foul smelling, mucus like, greasy, or poorly formedFrequent loss of appetite

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 0 1 2 3

0 1 2 30 1 2 3

Category VIIAbdominal distention after consumption of fiber, starches, and sugarAbdominal distention after certain probiotic or natural supplementsDecreased gastrointestinal motility, constipationIncreased gastrointestinal motility, diarrheaAlternating constipation and diarrheaSuspicion of nutritional malabsorptionFrequent use of antacid medicationHave you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?

Category VIII Greasy or high-fat foods cause distressLower bowel gas and/or bloating several hours after eatingBitter metallic taste in mouth, especially in the morningBurpy, fishy taste after consuming fish oilsUnexplained itchy skinYellowish cast to eyesStool color alternates from clay colored to normal brownReddened skin, especially palmsDry or flaky skin and/or hairHistory of gallbladder attacks or stonesHave you had your gallbladder removed?

Category IX Acne and unhealthy skinExcessive hair lossOverall sense of bloatingBodily swelling for no reasonHormone imbalancesWeight gainPoor bowel functionExcessively foul-smelling sweat

Category XCrave sweets during the dayIrritable if meals are missedDepend on coffee to keep going/get startedGet light-headed if meals are missedEating relieves fatigueFeel shaky, jittery, or have tremorsAgitated, easily upset, nervousPoor memory, forgetful between mealsBlurred vision

Category XIFatigue after mealsCrave sweets during the dayEating sweets does not relieve cravings for sugarMust have sweets after mealsWaist girth is equal or larger than hip girthFrequent urinationIncreased thirst and appetiteDifficulty losing weight

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 Yes No

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3

Category XII Cannot stay asleepCrave saltSlow starter in the morningAfternoon fatigueDizziness when standing up quicklyAfternoon headachesHeadaches with exertion or stressWeak nails

Category XIIICannot fall asleepPerspire easilyUnder a high amount of stressWeight gain when under stress Wake up tired even after 6 or more hours of sleepExcessive perspiration or perspiration with little or no activity

Category XIV Edema and swelling in ankles and wristsMuscle crampingPoor muscle enduranceFrequent urinationFrequent thirstCrave saltAbnormal sweating from minimal activityAlteration in bowel regularityInability to hold breath for long periodsShallow, rapid breathing

Category XVTired/sluggishFeel cold―hands, feet, all overRequire excessive amounts of sleep to function properlyIncrease in weight even with low-calorie dietGain weight easilyDifficult, infrequent bowel movementsDepression/lack of motivationMorning headaches that wear off as the day progressesOuter third of eyebrow thinsThinning of hair on scalp, face, or genitals, or excessive hair lossDryness of skin and/or scalpMental sluggishness

Category XVIHeart palpitationsInward tremblingIncreased pulse even at restNervous and emotionalInsomnia

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3 0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3 0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No Yes No Yes No Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

_______ years Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Category XVI (Cont.) Night sweatsDifficulty gaining weight

Category XVII (Males Only)Urination difficulty or dribblingFrequent urinationPain inside of legs or heelsFeeling of incomplete bowel emptyingLeg twitching at night

Category XVIII (Males Only)Decreased libidoDecreased number of spontaneous morning erectionsDecreased fullness of erectionsDifficulty maintaining morning erectionsSpells of mental fatigueInability to concentrateEpisodes of depressionMuscle sorenessDecreased physical staminaUnexplained weight gainIncrease in fat distribution around chest and hipsSweating attacksMore emotional than in the past

Category XIX (Menstruating Females Only)PerimenopausalAlternating menstrual cycle lengthsExtended menstrual cycle (greater than 32 days)Shortened menstrual cycle (less than 24 days)Pain and cramping during periodsScanty blood flowHeavy blood flowBreast pain and swelling during mensesPelvic pain during mensesIrritable and depressed during mensesAcneFacial hair growthHair loss/thinning

Category XX (Menopausal Females Only)How many years have you been menopausal?Since menopause, do you ever have uterine bleeding?Hot flashesMental fogginessDisinterest in sexMood swingsDepressionPainful intercourseShrinking breastsFacial hair growthAcneIncreased vaginal pain, dryness, or itching

PART III

How many alcoholic beverages do you consume per week? How many caffeinated beverages do you consume per day? How many times do you eat out per week? How many times do you eat raw nuts or seeds per week?List the three worst foods you eat during the average week:List the three healthiest foods you eat during the average week:PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Rate your stress level on a scale of 1-10 during the average week:How many times do you eat fish per week?How many times do you work out per week?

© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3

© 2016 Datis Kharrazian. All Rights Reserved. SMGENTAF(032116)

Name: _____________________________________Age: ______ Sex: ________ Date:______________________

Neurotransmitter Assessment Form™ (NTAF)

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

SECTION A• 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?

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

SECTION B• 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?

SECTION C SECTION C1

• 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?

SECTION C2

• 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?

SECTION 1• 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?

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

0 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

© 2016 Datis Kharrazian. All Rights Reserved. SMGENTAF(032116)

SECTION 2• 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 temper for minor reasons?

• How often do you have feelings of worthlessness?

SECTION 3• 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?

SECTION 4• 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?

SECTION 5• A decrease in mental alertness

• A decrease in mental speed

• A decrease in concentration quality

• Slow cognitive processing

• Impaired mental performance

• An increase in the ability to be distracted

• Need coffee or caffeine sources to improve mental function

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

0 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

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

Neurotransmitter Assessment Form™ (NTAF)