15541-B Beach Blvd
Westminster, CA 92683

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Health Questionnaire

Name
Age
Sex
Date
MM slash DD slash YYYY
* Please select the appropriate number “0 - 3” 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 things?
How often do you have a hard time remembering your appointments?
Is your temperament getting worse in general?
Are you losing your attention span endurance?
How often do you fi nd yourself down or sad?
How often do you fatigue when driving compared to the past?
How often do you fatigue when reading compared to 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 that 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?
Are you getting regular exercise?
Do you think people don’t care about you?
Do you feel you are not accomplishing your life’s purpose?
Do you have no one to share your problems with?
Section C
Section C1
How often do you get irritable, shaky, or have lightheadedness between meals?
How often do you feel energized after eating?
How often do you have diffi culty 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 diffi culty 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
Do you get fatigued after meals?
Do you crave sugar and sweets after meals?
Do you feel you need stimulants such as coffee after meals?
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 been increased?
Do you have weight gain when under stress?
Do you have diffi culty falling asleep?
Section 1 - S
Are you losing your pleasure in hobbies and interests?
How often do you feel overwhelmed with ideas to manage?
How often do you have feelings of inner rage (anger)?
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 enjoyment for your favorite foods?
How much are you losing your enjoyment of friendships and relationships?
How often do you have diffi culty 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?
Section 2 - D
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 fi nish 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 - G
How often do you feel anxious or panic 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 diffi cult 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 - ACH
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 been diminished?
Do you have diffi culty calculating numbers?
Do you have diffi culty recognizing objects & faces?
Do you feel like your opinion about yourself has changed?
Are you experiencing excessive urination?
Are you experiencing slower mental response?
Medication History
Please select any of the following medication you have been or are currently taking.
Acetylcholine Receptor Antagonist – Antimuscarinic Agents
- Atropine
- Ipratopium
- Scopolamine
- Tiotropium
Acetylcholine Receptor Antagonist - Ganlionic Blockers
- Mecamylamine
- Hexamethonium
- Nicotine (high doses)
- Trimethaphan
Acetylcholinesterase Reactivators
- Pralidoxime
Acetylcholine Receptor Antagonist - Neuromuscular Blockers
- Atracurium
- Cisatracurium
- Doxacurium
- Metocurine
- Mivacurium
- Pancuronium
- Rocuronium
- Uccinylcholine
- Tubocurarine
- Vecuronium
- Hemicholine
Agonist Modulator of GABA Receptor (benzodiazpines)
- Xanax
- Lexotanil
- Lexotan
- Librium
- Klonopin
- Valium
- ProSon
- Rohypnol
- Dalmane
- Ativan
- Loramet
- Sedoxil
- Dormicum
- Megadon
- Serax
- Restoril
- Halcion
Agonist Modulator of GABA Receptors (nonbenzodiazpines)
- Ambien
- Sonata
- Lunesta
- Imovane
Cholinesterase Inhibitors (irreversible)
- Echotiophate
- Isofl urophate
- Organophosphate Insecticides
- Organophosphate-containing nerve agents
Cholinesterase Inhibitors (reversible)
- Donepezil
- Galatamine
- Rivastigmine
- Tacrine
- THC
- Erophonium
- Neostigmine
- Phystigimine
- Pyridostigmine
- Carbamate Insecticidses
Dopamine Reuptake Inhibitors
- Wellbutrin (Bupropion)
Dopamine Receptor Agonists
- Mirapex
- Sifrol
- Requip
D2 Dopamine Receptor Blockers (antipsychotics)
- Thorazine
- Prolixin
- Trilafon
- Compazine
- Mellaril
- Stelazine
- Vesprin
- Nozinan
- Depixol
- Navane
- luanxol
- Clopixol
- Acuphase
- Haldol
- Orap
- Clozaril
- Zyprexa
- Zydis
- Seroquel
- Geodon
- Solian
- Invega
- Abilify
GABA Antagonist Competitive binder
- Flumazenil
Monoamine Oxidase Inhibitor (MAOI)
- Marplan
- Aurorix
- Maneric
- Moclodura
- Nardil
- Adlegiine
- Elepryl
- Azilect
- Marsilid
- Iprozid
- Ipronid
- Rivivol
- Popilniazida
- Zyvox
- Zyvoxid
Noradrenergic and Specifi c Sertonergic Antidepressants (NaSSaa)
- Remeron
- Zispin
- Avanza
- Norset
- Remergil
- Axit
Selective Serotonin Reuptake Inhibitor
- Paxil
- Zoloft
- Prozac
- Celexa
- Lexapro
- Luvox
- Cipramil
- Emocal
- Serpam
- Seropram
- Cipralex
- Esteria
- Fontex
- Seromex
- Seronil
- Sarafem
- Fluctin
- Faverin
- Seroxat
- Aropax
- Deroxat
- Rexetin
- Xentor
- Paroxat
- Lustral
- Serlain
- Dapoxetine
Selective Serotonin Reuptake Enhancers
- Stablon
- Coaxil
- Tatinol
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
- Effexor
- Pristiq
- Meridia
- Serzone
- Dalcipran
- Despramine
- Duloxetine
Tricylic Antidepresseants (TCAs)
- Elavil
- Endep
- Tryptanol
- Trepiline
- Asendin
- Asendis
- Defanyl
- Demolox
- Moxadil
- Anafranil
- Norpramin
- Pertofrane
- Prothiadin
- Thanden
- Adapin
- Sinequan
- Trofranil
- Janamine
- Gamanil
- Aventyl
- Pamelor
- Opipramol
- Vivactil
- Rhotrimine
- Surmontil
Email
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Asher Chiropractic

15541-B Beach Blvd
Westminster, CA 92683

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Business Hours

Mon: 9am-12pm & 2pm-5pm
Tue: 9am-12pm & 2pm-6pm
Wed: Closed
Thu: 9am-12pm & 2pm-6pm
Fri: 9am-12pm & 2pm-6pm
Sat: By Appointment Only
Sun: Closed

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