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Home Health Questionnaire (NTAF)

Health Questionnaire (NTAF)

Name

Age

Sex Male Female

Phone

Date

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 find 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?

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 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 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

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 difficulty 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 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?

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 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 - 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 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 - 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 None

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 Isoflurophate 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) None

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 None

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

*Please refer to prescribing physician for nutritional interactions with any medications you maybe taking.

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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