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Home Child Neurotransmitter Assessment

Child Neurotransmitter Assessment

Name

Phone

Age

Sex Yes No

Date

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

SECTION: GENERAL

Does your child have any food sensitivities or allergies? (please list)

List your child’s 4 healthiest foods eaten regularly.

List your child’s 4 unhealthiest foods eaten regularly

How many times a week does your child eat candy?

How many times a week does your child drink soda pop?

Please list the top 4 foods your child craves regularly?

List the medication(s) your child is currently prescribed and over the counter

Do you find it difficult as a parent to have your child on a special diet?

SECTION: A (K52)

Does your child eat pasta, breads, and breaded foods?

Does your child have symptoms (fatigue, hyperactivity, etc.) after eating wheat foods?

Does your child eat dairy products?

Does your child have symptoms (fatigue, hyperactivity, etc.) after eating dairy products?

SECTION: B (K53)

Does your child eat fried fish?

Does your child eat roasted nuts or seeds?

Is your child missing essential fatty acid rich foods in his/her diet? (for example: avocadoes, flax seeds, olives) (mark “0” if present, “3” if missing)

Does your child eat fried foods?

SECTION: C (K34)

Is your child’s mental speed slow?

Does your child have difficulty with learning or memory?

Does your child have difficulty with balance and coordination?

SECTION: D (K16)

Does your child have stress?

Does your child not have enough sleep and rest? (mark “3” if not enough)

Does your child not have regular exercise? (mark “3” if no exercise)

Does your child feel overly worried and scared?

SECTION: E (K16, K51)

Does your child have temper tantrums?

Does your child exhibit wild behavior?

Does your child frequently yell or scream for unnecessary reasons?

Does your child have an inability to nap or sleep when physically exhausted? (mark “3” if unable)

Is your child overly talkative?

Does your child fidget and squirm when seated?

Does your child run and climb excessively when it is inappropriate?

Does your child have difficulty playing quietly or engaging in leisure activities?

SECTION: F (K51)

Does your child get excited easily?

Does your child have anxiousness and panic for minor reasons?

Does your child feel overwhelmed for minor reasons?

Does your child find it difficult to relax when she/he is awake?

Does your child have disorganized attention?

SECTION: G (K50)

Does your child seem depressed?

Does your child have mood changes with overcast weather?

Does your child have symptoms of inner rage?

Does your child seem uninterested in games or hobbies?

Does your child have difficulty falling into deep restful sleep?

Does your child seem uninterested in friendships?

Does your child have symptoms of unprovoked anger?

Does your child seem uninterested in eating?

SECTION: H (K49)

Does your child have difficulty handling stress?

Does your child have anger and aggression while being challenged?

Does your child feel tired even after long sleeps?

Does your child tend to isolate from others?

Does your child get distracted easily?

Does your child have constant need and desire for candy and sugar?

Does your child have disorganized attention?

SECTION: I (K48)

Does your child have difficulty with visual memory?

Does your child have difficulty remembering locations?

Does your child have fatigue or low endurance for learning activities?

Does your child have difficulty with attention or low attention span or endurance?

Does your child have slow or difficult speech?

Does your child have uncoordinated or slow movement?

Please do not submit any Protected Health Information (PHI).

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Office Hours

Our regular schedule

ProNeuro Medical Group

Monday:

09:00 am - 06:00 pm

Tuesday:

09:00 am - 06:00 pm

Wednesday:

09:00 am - 06:00 pm

Thursday:

09:00 am - 06:00 pm

Friday:

09:00 am - 04:00 pm

Saturday:

09:00 am - 01:00 pm

Sunday:

Closed

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