Health QuestionnaireNameAgeSexDate Date Format: 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 AIs your memory noticeably declining?0123Are you having a hard time remembering names and phone numbers?0123Is your ability to focus noticeably declining?0123Has it become harder for you to learn things?0123How often do you have a hard time remembering your appointments?0123Is your temperament getting worse in general?0123Are you losing your attention span endurance?0123How often do you fi nd yourself down or sad?0123How often do you fatigue when driving compared to the past?0123How often do you fatigue when reading compared to the past?0123How often do you walk into rooms and forget why?0123How often do you pick up your cell phone and forget why?0123Section BHow high is your stress level?0123How often do you feel that you have something that must be done?0123Do you feel you never have time for yourself?0123How often do you feel you are not getting enough sleep or rest?0123Are you getting regular exercise?0123Do you think people don’t care about you?0123Do you feel you are not accomplishing your life’s purpose?0123Do you have no one to share your problems with?0123Section CSection C1How often do you get irritable, shaky, or have lightheadedness between meals?0123How often do you feel energized after eating?0123How often do you have diffi culty eating large meals in the morning?0123How often does your energy level drop in the afternoon?0123How often do you crave sugar and sweets in the afternoon?0123How often do you wake up in the middle of the night?0123How often do you have diffi culty concentrating before eating?0123How often do you depend on coffee to keep yourself going?0123How often do you feel agitated, easily upset, and nervous between meals?0123Section C2Do you get fatigued after meals?0123Do you crave sugar and sweets after meals?0123Do you feel you need stimulants such as coffee after meals?0123Do you have difficulty losing weight?0123How much larger is your waist girth compared to your hip girth?0123How often do you urinate?0123Have your thirst and appetite been increased?0123Do you have weight gain when under stress?0123Do you have diffi culty falling asleep?0123Section 1 - SAre you losing your pleasure in hobbies and interests?0123How often do you feel overwhelmed with ideas to manage?0123How often do you have feelings of inner rage (anger)?0123How often do you have feelings of paranoia?0123How often do you feel sad or down for no reason?0123How often do you feel like you are not enjoying life?0123How often do you feel you lack artistic appreciation?0123How often do you feel depressed in overcast weather?0123How much are you losing your enthusiasm for your favorite activities?0123How much are you losing enjoyment for your favorite foods?0123How much are you losing your enjoyment of friendships and relationships?0123How often do you have diffi culty falling into deep restful sleep?0123How often do you have feelings of dependency on others?0123How often do you feel more susceptible to pain?0123How often do you have feelings of unprovoked anger?0123How much are you losing interest in life?0123Section 2 - DHow often do you have feelings of hopelessness?0123How often do you have self-destructive thoughts?0123How often do you have an inability to handle stress?0123How often do you have anger and aggression while under stress?0123How often do you feel you are not rested even after long hours of sleep?0123How often do you prefer to isolate yourself from others?0123How often do you have unexplained lack of concern for family and friends?0123How easily are you distracted from your tasks?0123How often do you have an inability to fi nish tasks?0123How often do you feel the need to consume caffeine to stay alert?0123How often do you feel your libido has been decreased?0123How often do you lose your temper for minor reasons?0123How often do you have feelings of worthlessness?0123Section 3 - GHow often do you feel anxious or panic for no reason?0123How often do you have feelings of dread or impending doom?0123How often do you feel knots in your stomach?0123How often do you have feelings of being overwhelmed for no reason?0123How often do you have feelings of guilt about everyday decisions?0123How often does your mind feel restless?0123How diffi cult is it to turn your mind off when you want to relax?0123How often do you have disorganized attention?0123How often do you worry about things you were not worried about before?0123How often do you have feelings of inner tension and inner excitability?0123Section 4 - ACHDo you feel your visual memory (shapes & images) is decreased?0123Do you feel your verbal memory is decreased?0123Do you have memory lapses?0123Has your creativity been decreased?0123Has your comprehension been diminished?0123Do you have diffi culty calculating numbers?0123Do you have diffi culty recognizing objects & faces?0123Do you feel like your opinion about yourself has changed?0123Are you experiencing excessive urination?0123Are you experiencing slower mental response?0123Medication HistoryPlease select any of the following medication you have been or are currently taking.Acetylcholine Receptor Antagonist – Antimuscarinic Agents Atropine Ipratopium Scopolamine TiotropiumAcetylcholine Receptor Antagonist - Ganlionic Blockers Mecamylamine Hexamethonium Nicotine (high doses) TrimethaphanAcetylcholinesterase Reactivators PralidoximeAcetylcholine Receptor Antagonist - Neuromuscular Blockers Atracurium Cisatracurium Doxacurium Metocurine Mivacurium Pancuronium Rocuronium Uccinylcholine Tubocurarine Vecuronium HemicholineAgonist Modulator of GABA Receptor (benzodiazpines) Xanax Lexotanil Lexotan Librium Klonopin Valium ProSon Rohypnol Dalmane Ativan Loramet Sedoxil Dormicum Megadon Serax Restoril HalcionAgonist Modulator of GABA Receptors (nonbenzodiazpines) Ambien Sonata Lunesta ImovaneCholinesterase Inhibitors (irreversible) Echotiophate Isofl urophate Organophosphate Insecticides Organophosphate-containing nerve agentsCholinesterase Inhibitors (reversible) Donepezil Galatamine Rivastigmine Tacrine THC Erophonium Neostigmine Phystigimine Pyridostigmine Carbamate InsecticidsesDopamine Reuptake Inhibitors Wellbutrin (Bupropion)Dopamine Receptor Agonists Mirapex Sifrol RequipD2 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 AbilifyGABA Antagonist Competitive binder FlumazenilMonoamine Oxidase Inhibitor (MAOI) Marplan Aurorix Maneric Moclodura Nardil Adlegiine Elepryl Azilect Marsilid Iprozid Ipronid Rivivol Popilniazida Zyvox ZyvoxidNoradrenergic and Specifi c Sertonergic Antidepressants (NaSSaa) Remeron Zispin Avanza Norset Remergil AxitSelective 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 DapoxetineSelective Serotonin Reuptake Enhancers Stablon Coaxil TatinolSerotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Effexor Pristiq Meridia Serzone Dalcipran Despramine DuloxetineTricylic 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 SurmontilPhoneThis field is for validation purposes and should be left unchanged.
