Root Cause Analysis

Take The FREE RCA Health Assessment for Mind & Body Now

Click the 'Start' button below to begin your free root cause analysis health assessment. Your information is secure and confidential. The detailed questionnaire helps us uncover often overlooked issues by examining your full health history. While it may take some time to complete, the insights are worth it. You'll receive your results in a complimentary 30-minute strategy session, where we will discuss tailored recommendations for your health and wellness journey.

1. 

What are your main concerns?

General Physical Health

Mental Health: Depression, Anxiety etc.

Managing Chronic Illness Better

Stress/Burnout Management

Asthma/Respiratory issues

Allergies/Food Intolerances

Skin Conditions

Digestive Issues

Thyroid Issues

Trauma

Headaches/Migraines

Hair Loss

Menopause/Andropause Management

Chronic Fatigue

Fertility Issues

No Issues in particular but I'm curious

Toxic Mould in home & body

Nutrition

Weight loss/Weight gain

Mystery Illness/undiagnosed illness

Sleep issues

Sinus Problems

Reducing Toxic Body Burden (e.g., minimizing exposure to environmental toxins, detoxification)

Other: Please specify in the comment box

Comment

2. 

Have you previously sought treatment for these problems? If so, did you notice any changes in your condition? Were your blood tests results within normal ranges? Additionally, did you feel that your concerns were adequately addressed by your healthcare provider?

Yes, I have been to doctors (specify details in comments)

No, I have not sought treatment for these problems before.

Yes, I have tried other therapies or natural health specialists (specify details in comments)

Comment

3. 

Gender

Female

Male

None

Comment

4. 

IMMUNE SYSTEM HEALTH

Have you ever been diagnosed with an autoimmune disease?

Yes: Please specify which in comment box

No

None

Comment

5. 

IMMUNE SYSTEM HEALTH

Have you developed allergies or intolerances later in life or seasonal allergies such as hayfever?

Yes

No

None

Comment

6. 

IMMUNE SYSTEM HEALTH

Have you ever been diagnosed with a virus? If so, please specify which virus and the date of diagnosis.

Mono/Glandular Fever: Please in the comments when you were diagnosed with this

Epstein Barr Virus (EPV): Please in the comments when you were diagnosed with this

Herpes: Please in the comments when you were diagnosed with this

Chicken Pox: Please in the comments when you were diagnosed with this

Shingles: Please in the comments when you were diagnosed with this

Mumps: Please in the comments when you were diagnosed with this

I have never been diagnosed with any of these viruses or any other ones

Other: Please specify in comments along with when were you diagnosed

Comment

7. 

IMMUNE SYSTEM HEALTH

When stressed, do you experience: cold sores, hives, shingles, post nasal drip, nasal congestion, chronic fatigue or any other symptom?

Yes: Please specify in the comments

No

None

Comment

8. 

HORMONE HEALTH

Any sleep disturbances?

Insomnia

Sleep Apnea

Narcolepsy

Restless Legs Syndrome

Snoring

Other: Please specify in comments

No sleep issues

Comment

9. 

HORMONE HEALTH

When you wake up in the morning, do you generally feel energized and ready to start the day, or do you feel the need to sleep longer?

Energized and ready to start the day

I feel the need to sleep longer

None

10. 

HORMONE HEALTH

Do you feel tired regardless of the amount of hours you sleep?

Yes

No

None

11. 

HORMONE HEALTH

Do you get cravings for sugar OR salt?

Sugar cravings

Salt cravings

No cravings

12. 

THYROID HEALTH,HORMONE HEALTH

Do you experience any weight-related issues regardless of your diet or exercise regimen?

I have difficulty losing weight

I Have difficulty gaining weight

I have difficulty with both losing and gaining weight

I easily gain weight

I easily lose weight

No, I do not have difficulty with weight changes

13. 

THYROID HEALTH

Do you get cold hands/feet?

Yes

No

None

14. 

THYROID HEALTH

Do you experience constipation?

Yes

No

Occasionally

None

15. 

THYROID HEALTH

Do you have history of high cholesterol?

Yes

No

None

16. 

THYROID HEALTH

Did your doctor test your TSH, T3, T4, and thyroid antibodies levels?

No

Tested TSH Levels

Tested T3 Levels

Tested T4 Levels

Tested Antibodies Levels

17. 

THYROID HEALTH

Has your doctor investigated your gut and immune health?

Yes: Please specify how in the comments

No

None

Comment

18. 

ESTROGEN (for females)

Have you ever been diagnosed with any of the following conditions?

PCOS

Fibroids

Endometriosis

No, I have never been diagnosed with PCOS, fibroids, or endometriosis

No, I am male, so this question about PCOS, fibroids, or endometriosis does not apply to me

19. 

ESTROGEN (for females)

Do you have a history of migraines?

Yes

No

None

20. 

TESTOSTERONE (for males),ESTROGEN (for females)

Do you experience any of the following symptoms?

Hair loss

Low sex drive

Hot flashes

No, I have not experienced any hair loss, low sex drive, or hot flashes

21. 

ESTROGEN (for females)

What age did you get your first period? (Male respondents, please skip this question by pressing 'Next.')

22. 

ESTROGEN (for females)

What was the flow of that first period like?

I am male, so this question doesn't apply to me

Heavy

Light

Normal

Clotting

Can't remember

23. 

ESTROGEN (for females)

Do you get hives around your cycle?

Yes

No

Occasionally

No, I am male, so this question does not apply to me

None

24. 

ESTROGEN (for females)

Have you experienced irregular menstrual cycles?

Yes, recently

Yes, in the past but not now

No

No, I am male, so this question does not apply to me

None

25. 

ESTROGEN (for females)

Are you getting hair in unwanted places, face, chin, body?

Yes

No

None

26. 

ESTROGEN (for females)

If you are in menopause, at what age did it begin? If you are not, please press 'Next.' (Male respondents, please skip this question by pressing 'Next.')

27. 

BLOOD SUGAR HEALTH

Have you ever been diagnosed with Diabetes?

Yes, Type 1 Diabetes

Yes, Type 2 Diabetes

No

None

28. 

BLOOD SUGAR HEALTH

Do you frequently get thirsty?

Yes

No

Sometimes/Not sure

None

29. 

BLOOD SUGAR HEALTH

Do you frequently feel any of the following?

Frequently feel the urge to urinate

Feel tired/fatigued after a meal

Feel energized after a meal

No to all

30. 

BLOOD SUGAR HEALTH

Do you feel "hangry" in the morning before breakfast? (Hungry and angry)

Yes

No

Sometimes/Not sure

None

31. 

TESTOSTERONE (for males)

Do you experience frequent urination or difficulty urinating? (Female respondents, please skip this question by pressing 'Next.')

Frequent urination

Difficulty urinating

No to all

Comment

32. 

TESTOSTERONE (for males)

Do you suffer from baldness? (Female respondents, please skip this question by pressing 'Next.')

Yes

No

Receding

None

33. 

TESTOSTERONE (for males)

Do you have difficulty gaining muscle weight when working out? (Female respondents, please skip this question by pressing 'Next.')

Yes

No

None

34. 

DIGESTION

Do you experience gas and/or bloating after eating?

Yes

No

Sometimes

None

35. 

DIGESTION

How do you feel after taking probiotics? Have you experienced any problems?

I feel significantly better with no problems

I feel slightly better with no problems

I feel no different

I feel worse and experienced mild issues (e.g., bloating, gas)

I feel worse and experienced severe issues (e.g., severe digestive discomfort)

I haven't taken probiotics.

36. 

DIGESTION

Have you ever been diagnosed with any of the following conditions? Please tick all that apply: Stomach ulcers, Gastritis, SIBO (Small Intestinal Bacterial Overgrowth), Candida, Depression, ADHD.

Stomach ulcers

Gastritis

SIBO (Small Intestinal Bacterial Overgrowth)

Candida

Depression

ADHD

None of the above

37. 

DIGESTION

Do you experience skin itching/irritation frequently?

Yes

No

None

38. 

DIGESTION

Have you recently been experiencing food sensitivity/allergies to food not previously experienced?

Yes

No

None

Comment

39. 

DIGESTION

Do you have any skin conditions? (i.e. psoriasis, eczema, rosacea, acne, etc.)

Psoriasis

Eczema

Dermatitis

Rosacea

Boils

Acne

Other: Please specify in comments

No

Comment

40. 

DIGESTION

Do you tolerate alcohol badly?

Yes, I experience severe discomfort or adverse reactions with small amounts.

Yes, I experience mild discomfort or adverse reactions with small amounts.

Sometimes, it depends on the type or amount of alcohol.

No, I tolerate alcohol well with no significant issues.

I don't consume alcohol.

None

41. 

DIGESTION

How do you feel after taking Kombucha tea?

I feel significantly better with no problems.

I feel slightly better with no problems.

I feel no different.

I feel worse and experienced mild issues (e.g., bloating, gas)

I feel worse and experienced severe issues (e.g., severe digestive discomfort).

I haven't tried Kombucha tea.

42. 

TRIGGERS, ALLERGENS, EXPOSURES

Have you lived in, worked in or travelled to a space with mold (past or present)? If so, when and for how long were you exposed?

Yes, I currently live in a space with mold.

Yes, I previously lived in a space with mold but not anymore.

Yes, I have worked in a space with mold.

Yes, I have previously worked in a space with mold but not anymore.

Yes, I have traveled to a space with mold for a short period (e.g., vacation).

No, I have not been exposed to mold that I am aware of.

Comment

43. 

TRIGGERS, ALLERGENS, EXPOSURES

Do you have white spots (no pigmentation or low pigmentation) on the skin?

Yes

No

Not sure

None

44. 

TRIGGERS, ALLERGENS, EXPOSURES

Do you have any reactions to foods? (Eg. Dizziness, nausea, diarrhoea, skin irritation, discomfort)

Yes: Please specify in the comments

No

Not sure

None

Comment

45. 

TRIGGERS, ALLERGENS, EXPOSURES

Do you get red cheeks when drinking alcohol?

Yes

No

I have in the past, but not anymore

None

46. 

TRIGGERS, ALLERGENS, EXPOSURES

Are you sensitive to light, smells, chemicals, medications or sound? If so, what is the response you have and to what?

Yes, I am sensitive to light (please specify your reactions in the comments).

Yes, I am sensitive to smells (please specify your reactions in the comments).

Yes, I am sensitive to chemicals (please specify your reactions in the comments).

Yes, I am sensitive to medications (please specify your reactions in the comments).

Yes, I am sensitive to sound (please specify your reactions in the comments).

Yes, I am sensitive to multiple stimuli (please specify your reactions in the comments).

No, I am not sensitive to any of these.

Comment

47. 

TRIGGERS, ALLERGENS, EXPOSURES

Do you experience problems with any of the following: Coffee, dairy, green tea, red wine, grapes, mushrooms, dark chocolate, or apple cider vinegar? Please tick all that apply, even if it has only happened once.

Coffee

Dairy

Green Tea

Red Wine

Grapes

Mushrooms

Dark Chocolate

Apple Cider Vinegar

I do not have any issues with coffee, dairy, green tea, red wine, grapes, mushrooms, dark chocolate, or apple cider vinegar.

48. 

TRADITIONAL MEDICINE

Please list any medications you are currently taking for health conditions and what you are taking them for. Do these medications help alleviate symptoms or create new ones?

I'm not currently taking any medications

The medications I am currently taking help alleviate symptoms (please specify in comments which medications you are on and what you are taking them for)

The medications I am currently taking create new symptoms (please specify in comments which medications you are on and what you are taking them for).

The medications I am currently taking both alleviate and create new symptoms (please specify in comments which medications you are on and what you are taking them for).

The medications I am currently taking neither alleviate nor create new symptoms (please specify in comments which medications you are on and what you are taking them for).

None

Comment

49. 

ALTERNATIVE MEDICINE

Are you currently taking any supplements?

I'm not currently taking any supplements

Yes: Please list all of the supplements you are taking in the comments & what you are taking them for

None

Comment

50. 

ALTERNATIVE MEDICINE

Do the supplements you are taking help alleviate symptoms or create new symptoms? If you are not taking any supplements, please press 'Next.

Yes, they help alleviate symptoms with no new symptoms.

Yes, they help alleviate symptoms but create mild new symptoms (please specify in comments).

Yes, they help alleviate symptoms but create severe new symptoms (please specify in comments).

No, they do not alleviate symptoms and create mild new symptoms (please specify in comments).

No, they do not alleviate symptoms and create severe new symptoms (please specify in comments).

No, they do not alleviate symptoms and do not create new symptoms.

None

Comment

51. 

SURGERIES

Do you have any history of surgeries?

Yes: If so when? Why was this performed? Please specify details in comments

No surgeries

None

Comment

52. 

TIMELINE

Were you a natural birth or C- section?

C-Section

Natural Birth

Not sure/can't find out

None

Comment

53. 

TIMELINE

Were you breast or bottle fed?

Bottle fed

Breast fed

Not sure/Can't find out

None

Comment

54. 

TIMELINE

Were you sick as a child? Did you get fevers or allergies when sick?

Yes, I was frequently sick with fevers (please specify in the comments).

Yes, I was frequently sick with allergies (please specify in the comments).

No, I was rarely or never sick as a child.

Comment

55. 

TIMELINE

Did you have recurrent sore throats, ear infections or stuffy nose growing up?

Yes, I had recurrent sore throats

Yes, I had recurrent ear infections

Yes, I had a recurrent stuffy nose

Yes, I had all of these

No, I did not have any of these issues.

None

56. 

TIMELINE

Do you get sick now when stressed? Are these infections treated with antibiotics or other treatments?

Yes, I get sick when stressed and usually require antibiotics

Yes, I get sick when stressed and usually require other treatments (please specify in the comments).

Yes, I get sick when stressed and have used both antibiotics and other treatments (please specify in the comments).

Yes, I get sick when stressed but do not require professional treatment. I self-treat (please specify in the comments).

No, I do not get sick when stressed

Comment

57. 

TIMELINE

Are there any other health conditions or experiences (e.g., traumatic events, accidents, childhood experiences, food triggers, or others) not previously mentioned on this form? Please list them in chronological order if possible (from birth to today), including when and in what order things occurred, to help us identify the underlying causes. No detail is too unimportant.

No

Yes: Please specify in comments

None

Comment

58. 

Adverse Childhood Experience (ACE) Questionnaire

Did a parent or other adult in the household often: Swear at you, insult you, put you down, or humiliate you? Or Act in a way that made you afraid that you might be physically hurt?

Yes

No

None

59. 

Adverse Childhood Experience (ACE) Questionnaire

Did a parent or other adult in the household often: Push, grab, slap, or throw something at you? Or Ever hit you so hard that you had marks or were injured?

Yes

No

None

60. 

Adverse Childhood Experience (ACE) Questionnaire

Did an adult or person at least 5 years older than you ever: Touch or fondle you or have you touch their body in a sexual way? Or Attempt or actually have oral, anal, or vaginal intercourse with you?

Yes

No

None

61. 

Adverse Childhood Experience (ACE) Questionnaire

Did you often feel that: No one in your family loved you or thought you were important or special? Or Your family didn’t look out for each other, feel close to each other, or support each other?

Yes

No

None

62. 

Adverse Childhood Experience (ACE) Questionnaire

Did you often feel that: You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

Yes

No

None

63. 

Adverse Childhood Experience (ACE) Questionnaire

Were your parents ever separated or divorced?

Yes

No

None

64. 

Adverse Childhood Experience (ACE) Questionnaire

Were any of your parents or other adult caregivers: Often pushed, grabbed, slapped, or had something thrown at them? Or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Yes

No

None

65. 

Adverse Childhood Experience (ACE) Questionnaire

Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

Yes

No

None

66. 

Adverse Childhood Experience (ACE) Questionnaire

Was a household member depressed or mentally ill, or did a household member attempt suicide?

Yes

No

None

67. 

Adverse Childhood Experience (ACE) Questionnaire

Did a household member go to prison?

Yes

No

None

68. 

Emotional Inflammation Assessment Form

When you read the newspaper or see the news or online news feeds and find out about the latest scandal, crisis, or threat, how do you typically respond? Choose the closest answer that resonates.

A. I feel nervous and find it difficult to deal with events that disrupt my sometimes-fragile equilibrium.

B. I tend to feel revved up because I feel like I have to be hyper-vigilant in order to stay on top of what’s going on. I am likely to keep checking for updates.

C. I get P.O.ed about what a dangerous circus the world has turned into and may become antagonistic toward people who challenge me.

D. I vow to avoid those reports and find myself withdrawing from people and activities to conserve my personal energy.

None

69. 

Emotional Inflammation Assessment Form

When you first wake up in the morning, what thoughts and feelings typically go through your mind? Choose the closest answer that resonates.

A. I often have a vague sense if foreboding about what the day will bring and a fear that I don’t have enough stamina to meet the demands I’ll face.

B. I need to pop out of bed and get started on my to-do list ASAP, so I can avoid the tsunami of issues that may amp me up.

C. I often focus on the injustices and misbehaviour of the day before that made me feel disrespected or even outraged.

D. I usually want to roll over and go back to sleep.

None

70. 

Emotional Inflammation Assessment Form

When you think about the world 10 years from now, what does it look like? Choose the closest answer that resonates.

A. It seems dark and frightening, with more storms, floods and fires and increasingly dysfunctional society and troubled political leadership.

B. It looks frantic and chaotic. People should be bust creating plans and stock piling provisions for survival.

C. It seems increasingly violent and mistrustful because political institutions have abdicated their responsibility for protecting us and people are looking out for themselves.

D. Honestly, I do just about anything to avoid thinking about it.

None

71. 

Emotional Inflammation Assessment Form

When you imagine hosting a large family dinner after a hectic week, what thoughts come to mind? Choose the closest answer that resonates.

A. I start stressing out about whether the food will be good enough and whether everyone will get along.

B. Thoughts fly through my mind about cleaning up the house, setting the table, envisioning the menu and competing other tasks and I feel like I’m on a runaway train.

C. I might feel resentful that once again, I’, going to be doing a disproportionate amount of the work physically or emotionally.

D. I start thinking about how to get out of various tasks that are required, I have a ‘what’s the point’ feeling.

None

72. 

Emotional Inflammation Assessment Form

When you hear about bad things such as a life-threatening illness or a serious accident happening to people you care about, what feelings typically go through your mind? Choose the closest answer that resonates.

A. I often feel like danger is getting too close for comfort and the protective layers in my life are wearing away.

B. I tend to push my feelings aside and swing into ‘what needs to be done’ mode.

C. I often wrestle with feelings about how unfair life is.

D. I tend to focus on the randomness of life which makes me want to take cover to protect myself.

None

73. 

Emotional Inflammation Assessment Form

When you’re in a social situation that’s discorded with your political, parental or personal values, how do you typically react? Choose the closest answer that resonates.

A. I want to change or neutralise the topic of the conversation to avoid conflict.

B. I might unleash a laundry list of injustices and other problems that disprove their assertions.

C. I might get confrontational and question other people’s judgment or morals.

D. I might disengage in that moment and consider not spending time with these people in the future.

None

74. 

Emotional Inflammation Assessment Form

When you find out about a new highly destructive storm, horrifying crime against humanity or other upsetting event, how do you generally feel physically? Choose the closest answer that resonates.

A. Vulnerable or afraid.

B. Jittery and amped up.

C. Hot and tense.

D. Depleted or exhausted.

None

75. 

Emotional Inflammation Assessment Form

When you consider whether your inner aspirations and the realities of your external life reflect each other or are in sync, what are you inclined to feel? Choose the closest answer that resonates.

A. Uneasy and insecure.

B. Pressured and impatient.

C. Cheated and disillusioned.

D. Discouraged and wistful.

None

76. 

Emotional Inflammation Assessment Form

When you are driving somewhere, commuting, walking the dog, taking a shower or doing something else that doesn’t require conscious thought, and your mind wanders, where might it go? Choose the closest answer that resonates.

A. I may imagine worst case scenarios that could happen with issues I am worried about in my personal life or in the world at large.

B. I might start thinking about what I could or should do to try to exert more control in my life.

C. I tend to feel irritated with others or frustrated with the human race in general and want to express those feelings.

D. Usually I just think about getting through the day, if I go beyond that, I might fantasise about how I can protect myself beyond the conflict and hostility around me.

None

77. 

Emotional Inflammation Assessment Form

What are some of the most common themes in your dreams these days? Choose the closest answer that resonates.

A. Apocalyptic themes or scenarios about getting lost or stuck in a dark or deep place or being surrounded by threatening or un trustworthy people.

B. Driving and the brakes stop working properly or a sense that time is running out or that things are falling in me.

C. Being wronged, demeaned, or bullied, or getting back at others for the wrongs they have committed.

D. Floating in a calm ocean and seeing land from afar but not wanting to approach it.

None

78. 

Emotional Inflammation Assessment Form

When you think about what worries or pre-occupies you the most, what are you naturally inclined to do? Choose the closest answer that resonates.

A. I am likely to start to feel on edge or rattled and get overly anxious about even minor stressors.

B. I get busy thinking of ways to deal with the problem and get others to do the same by getting involved in actions that address the issue.

C. I may become testy and lash out at others more easily over seemingly minor transgressions.

D. I would probably plan ways to comfort myself later by doing something that’s easy like binge watching favourite shows, handing out with a pet or engaging in another chill out activity.

None

79. 

Emotional Inflammation Assessment Form

When you’re stressed, what kinds of situations or activities tend to make you feel worse? Choose the closest answer that resonates.

A. Talking to people who have similar worries. Hearing other people’s fears and anxieties ratchets up my own.

B. Being told to slow down and relax, especially by people who fail to see the urgency behind some of the issues I care about.

C. Being around people who challenge my beliefs and values, or my take on current events.

D. Feeling judged as lazy or anti-social when I retreat or need personal time.

None

80. 

Neurotransmitter Assessment Form (Section A)

Is your ability to focus noticeably declining?Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

81. 

Neurotransmitter Assessment Form (Section A)

Has it become harder for you to learn new things? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

82. 

Neurotransmitter Assessment Form (Section A)

How often do you have a hard time remembering your appointments? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

83. 

Neurotransmitter Assessment Form (Section A)

Is your temperament generally getting worse? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

84. 

Neurotransmitter Assessment Form (Section A)

Is your attention span decreasing? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

85. 

Neurotransmitter Assessment Form (Section A)

How often do you find yourself down or sad? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

86. 

Neurotransmitter Assessment Form (Section A)

How often do you become fatigued when driving when compared to the past? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

87. 

Neurotransmitter Assessment Form (Section A)

How often do you walk into rooms and forget why? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

88. 

Neurotransmitter Assessment Form (Section A)

How often do you pick up your phone and forget why? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

89. 

Neurotransmitter Assessment Form (Section B)

How high is your stress level? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

90. 

Neurotransmitter Assessment Form (Section B)

How often do you feel you have something that must be done? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

91. 

Neurotransmitter Assessment Form (Section B)

Do you feel you never have time for yourself? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

92. 

Neurotransmitter Assessment Form (Section B)

How often do you feel you are not getting enough sleep or rest? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

93. 

Neurotransmitter Assessment Form (Section B)

Do you find it difficult to get regular exercise? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

94. 

Neurotransmitter Assessment Form (Section B)

Do you feel uncared for by the people in your life? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

95. 

Neurotransmitter Assessment Form (Section B)

Do you feel you are not accomplishing your life's purpose? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

96. 

Neurotransmitter Assessment Form (Section A)

Is your memory noticeably declining? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

97. 

Neurotransmitter Assessment Form (Section B)

Is sharing your problems with someone difficult for you? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

98. 

Neurotransmitter Assessment Form (Section C)

How often do you get irritable, shaky, or have light-headedness between meals? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

99. 

Neurotransmitter Assessment Form (Section C)

How often do you feel energized after eating? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

100. 

Neurotransmitter Assessment Form (Section C)

How often do you have difficulty eating large meals in the morning? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

101. 

Neurotransmitter Assessment Form (Section C)

How often does your energy level drop in the afternoon? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

102. 

Neurotransmitter Assessment Form (Section C)

How often do you crave sugar and sweets in the afternoon? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

103. 

Neurotransmitter Assessment Form (Section C)

How often do you wake up in the middle of the night? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

104. 

Neurotransmitter Assessment Form (Section C)

How often do you have difficulty concentrating before eating? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

105. 

Neurotransmitter Assessment Form (Section C)

How often do you depend on coffee to keep yourself going? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

106. 

Neurotransmitter Assessment Form (Section 1))

How often do you feel agitated, easily upset and nervous between meals? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

107. 

Neurotransmitter Assessment Form (Section A)

Are you having a hard time remembering names and phone numbers? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

108. 

Neurotransmitter Assessment Form (Section 1))

Are you losing interest in hobbies? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

109. 

Neurotransmitter Assessment Form (Section 1))

How often do you feel overwhelmed? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

110. 

Neurotransmitter Assessment Form (Section 1))

How often do you have feelings of inner rage? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

111. 

Neurotransmitter Assessment Form (Section 1))

How often do you have feelings of paranoia? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

112. 

Neurotransmitter Assessment Form (Section 1))

How often do you feel sad or down for no reason? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

113. 

Neurotransmitter Assessment Form (Section 1))

How often do you feel like you are not enjoying life? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

114. 

Neurotransmitter Assessment Form (Section 1))

How often do feel you lack artistic appreciation? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

115. 

Neurotransmitter Assessment Form (Section 1))

How often do you feel depressed in overcast weather? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

116. 

Neurotransmitter Assessment Form (Section 1))

How much are you losing your enthusiasm for your favourite activities? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

117. 

Neurotransmitter Assessment Form (Section 1))

How much are you losing your enjoyment for your favourite foods? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

118. 

Neurotransmitter Assessment Form (Section 1))

How much are you losing your enjoyment of friendships and relationships? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

119. 

Neurotransmitter Assessment Form (Section 1))

How often do you have difficulty falling into deep or restful sleep? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

120. 

Neurotransmitter Assessment Form (Section 1))

How often do you have feelings of dependency on others? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

121. 

Neurotransmitter Assessment Form (Section 1))

How often do you feel more susceptible to pain? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

122. 

Neurotransmitter Assessment Form (Section 1))

How often do you have feelings of unprovoked anger? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

123. 

Neurotransmitter Assessment Form (Section 1))

How much are you losing interest in life? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

124. 

Neurotransmitter Assessment Form (Section 2)

How often do you have feelings of hopelessness? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

125. 

Neurotransmitter Assessment Form (Section 2)

How often do you have self-destructive thoughts? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

126. 

Neurotransmitter Assessment Form (Section 2)

How often do you have an inability to handle stress? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

127. 

Neurotransmitter Assessment Form (Section 2)

How often do you have anger and aggression under stress? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

128. 

Neurotransmitter Assessment Form (Section 2)

How often do you feel you are not rested, even after long hours of sleep? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

129. 

Neurotransmitter Assessment Form (Section 2)

How often do you prefer to isolate yourself from others? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

130. 

Neurotransmitter Assessment Form (Section 2)

How often do you have unexplained lack of concern for family and friends? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

131. 

Neurotransmitter Assessment Form (Section 2)

How easily are you distracted from your tasks? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

132. 

Neurotransmitter Assessment Form (Section 2)

How often do you have an inability to finish tasks? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

133. 

Neurotransmitter Assessment Form (Section 2)

How often do you feel the need to consume caffeine to stay alert? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

134. 

Neurotransmitter Assessment Form (Section 2)

How often do you feel your libido has decreased? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

135. 

Neurotransmitter Assessment Form (Section 2)

How often do you lose your temper for minor reasons? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

136. 

Neurotransmitter Assessment Form (Section 2)

How often do you have feelings of worthlessness? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

137. 

Neurotransmitter Assessment Form (Section 3))

How often do you feel anxious or panicked for no reason? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

138. 

Neurotransmitter Assessment Form (Section 3))

How often do you have feelings of dread or impending doom? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

139. 

Neurotransmitter Assessment Form (Section 3))

How often do you feel knots in your stomach? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

140. 

Neurotransmitter Assessment Form (Section 3))

How often do you have feelings of being overwhelmed for no reason? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

141. 

Neurotransmitter Assessment Form (Section 3))

How often do you have feelings of guilt about everyday decisions? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

142. 

Neurotransmitter Assessment Form (Section 3))

How often does your mind feel restless? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

143. 

Neurotransmitter Assessment Form (Section 3))

How difficult is it to turn your mind off when you want to relax? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

144. 

Neurotransmitter Assessment Form (Section 3))

How often do you have disorganized attention? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

145. 

Neurotransmitter Assessment Form (Section 3))

How often do you worry about things you were not worried about before? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

146. 

Neurotransmitter Assessment Form (Section 3))

How often do you have feelings of inner tension and inner excitability? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

147. 

Neurotransmitter Assessment Form (Section 4)

Do you feel your visual memory (shapes and images) has decreased? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

148. 

Neurotransmitter Assessment Form (Section 4)

Do you feel your verbal memory has decreased? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

149. 

Neurotransmitter Assessment Form (Section 4)

Do you have memory lapses? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

150. 

Neurotransmitter Assessment Form (Section 4)

Has your creativity decreased? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

151. 

Neurotransmitter Assessment Form (Section 4)

Has your comprehension diminished? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

152. 

Neurotransmitter Assessment Form (Section 4)

Do you have difficulty calculating numbers? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

153. 

Neurotransmitter Assessment Form (Section 4)

Do you have difficulty recognising objects and faces? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

154. 

Neurotransmitter Assessment Form (Section 4)

Do you feel like your opinion about yourself has changed? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

155. 

Neurotransmitter Assessment Form (Section 4)

Are you experiencing excessive urination? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

156. 

Neurotransmitter Assessment Form (Section 4)

Are you experiencing a slower mental response? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

157. 

Neurotransmitter Assessment Form (Section 5)

A decrease in mental alertness? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

158. 

Neurotransmitter Assessment Form (Section 5)

A decrease in mental speed? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

159. 

Neurotransmitter Assessment Form (Section 5)

A decrease in concentration quality? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

160. 

Neurotransmitter Assessment Form (Section 5)

Slow cognitive processing? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

161. 

Neurotransmitter Assessment Form (Section 5)

Impaired mental performance? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

162. 

Neurotransmitter Assessment Form (Section 5)

An increase in the ability to be distracted? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

163. 

Neurotransmitter Assessment Form (Section 5)

Need coffee or caffeine sources to improve mental function? Please check the appropriate number 0 as the least/never to 3 as the most/always.

0

1

2

3

None

164. 

Medication History

Please check any of the following medications of Noradrenergic and Specific Seratonergic Antidepressants (NaSSAs) below that you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Noradrenergic and Specific Seratonergic Antidepressants

Zispin ®️

Avanza ®️

Norset ®️

Remergil ®️

Axit ®️

Remeron ®️

165. 

Medication History

Tricyclic Antidepressants (TCAs). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Tricyclic Antidepressants (TCAs)

Norpramin ®️

Asendin ®️

Trepiline ®️

Tryptanol ®️

Endep ®️

Asendis ®️

Defanyl ®️

Demolex ®️

Moxadil ®️

Anafranil ®️

Petrofrane®️

Prothiaden ®️

Thaden ®️

Adapin ®️

Sinequan ®️

Tofranil ®️

Janamine ®️

Gamanil ®️

Aventyl ®️

Vivactil ®️

Pamelor®️

Opipramol ®️

Rhotrimine ®️

Surmontil ®️

Elavil ®️

166. 

Medication History

Selective Serotonin Reuptake Inhibitors (SSRIs). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Selective Serotonin Reuptake Inhibitors (SSRIs)

Serlain ®️

Lexapro ®️

Celexa®️

Prozac ®️

Zoloft ®️

Esertia ®️

Luvox ®️

Cipramil ®️

Fontex ®️

Priligy ®️

Seromex ®️

Seronil ®️

Sarafem ®️

Fluctin ®️

Faverin ®️

Seroxat ®️

Aropax ®️

Deroxat ®️

Rexetin ®️

Paroxat ®️

Lustral ®️

Paxil ®️

167. 

Medication History

Serotonin- Norepinephrine Reuptake Inhibitors (SNRIs). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Serotonin- Norepinephrine Reuptake Inhibitors (SNRIs)

Cyambalta ®️

Dalcipran ®️

Serzone ®️

Pristiq ®️

Effexor ®️

168. 

Medication History

Selective Serotonin Reuotajke Enhancers (SSREs). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Selective Serotonin Reuotajke Enhancers (SSREs)

Tatinol ®️

Coaxil ®️

Stablon ®️

169. 

Medication History

Monoamine Ocidase Inhibitors (MAOIs). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Monoamine Ocidase Inhibitors (MAOIs)

Zyvoxid ®️

Moclodura ®️

Manerix ®️

Nardil ®️

Aurorix ®️

Adeline ®️

Eldepryl ®️

Azilect ®️

Marsilid ®️

Iprozid ®️

Ipronid ®️

Rivivol ®️

Propilniazida ®️

Zyvox ®️

Marplan ®️

170. 

Medication History

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

I have not taken in the past or am currently taking any Dopamine Receptor Agonists

Requip ®️

Sifrol ®️

Mirapex ®️

171. 

Medication History

Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs)

Wellbutrin XL ®️

172. 

Medication History

D2 Dopamine Receptor Blockers (antopsychotics). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any D2 Dopamine Receptor Blockers (antopsychotics)

Abilify ®️

Compazine ®️

Prolixin ®️

Trilafon ®️

Mellaril®️

Stelazine ®️

Vesprin ®️

Nozinan ®️

Depixol ®️

Navanc ®️

Fluanxol ®️

Clopixol ®️

Acuphase ®️

Haldol ®️

Orap ®️

Clozaril®️

Zyprexa ®️

Zydis ®️

Seroquel XR ®️

Geodon ®️

Solian ®️

Invega ®️

Thorazine ®️

173. 

Medication History

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

I have not taken in the past or am currently taking any GABA Antagonist Competitive Binders

Romazicon ®️

174. 

Medication History

Agonist Modulators of GABA Receptors (benzodiazepines). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Agonist Modulators of GABA Receptors (benzodiazepines)

Halcion ®️

Klonopin ®️

Lexotan ®️

Lexotanil ®️

Valium ®️

Prosom ®️

Rohypnol ®️

Magadon ®️

Dalmane ®️

Ativan ®️

Loramet ®️

Sedoxil®️

Dormicum ®️

Serax ®️

Restoril ®️

Xanax ®️

175. 

Medication History

Agonist Modulators of GABA Receptors (non-benzodiazepines). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Agonist Modulators of GABA Receptors (non-benzodiazepines)

Lunesta ®️

Sonata ®️

Ambien CR ®️

Imovane ®️

176. 

Medication History

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

I have not taken in the past or am currently taking any Acetylcholine Receptor Agonists

Isopto ®️

Salagen ®️

Evoxac ®️

Urecholine ®️

Nicotone

177. 

Medication History

Acetylcholine Receptor Antagonists (antimuscarnic agents). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Acetylcholine Receptor Antagonists (antimuscarnic agents)

Spiriva ®️

Atrovent ®️

Scopace ®️

AtroPen ®️

178. 

Medication History

Acetylcholine Receptor Antagonists (neuromuscular blockers). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Acetylcholine Receptor Antagonists (neuromuscular blockers)

Hemicholinium-3 ®️

Metubine ®️

Nuromax ®️

Nimbex ®️

Mivacron ®️

Pavulon ®️

Zemuron ®️

Anectine ®️

Tubocurarine ®️

Norcuron ®️

Tracrium ®️

179. 

Medication History

Acetylcholine Receptor Antagonists (ganglionic blockers). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Acetylcholine Receptor Antagonists (ganglionic blockers)

Hexamethonium

Inversine ®️

Arfonad ®️

Acetylcholineesterase Reactivators

Proptopam ®️

Nicotine (high doses)

180. 

Medication History

Cholinesterase Inhibitors (reversible). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Cholinesterase Inhibitors (reversible)

Mestinon ®️

Cognex ®️

Exelon®️

Razadyne ®️

THC

Carbanate insecticides

Enlon ®️

Prostigmin ®️

Antilirium ®️

Aricept ®️

181. 

Medication History

Cholinesterase Inhibitors (irreversible). Please check any of the following medications you have taken in the past or are currently taking.

I have not taken in the past or am currently taking any Cholinesterase Inhibitors (irreversible)

Organophosphate-containing nerve agents

Organophosphate insecticides

Isoflurophate

Echoiophate

182. 

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183. 

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