• Patient Introduction

  • Personal History:

  •  - -

  • Neurotransmitter Assessment Form

    (NTAF)
  •  - -

  • Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

  • SECTION A

  • SECTION B

  • SECTION C

    SECTION C1

  • SECTION C2

  • SECTION 1

  • SECTION 2

  • SECTION 3

  • SECTION 4

  • Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition

  • Medication History

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

  • Metabolic Assessment Form

  •  - -

  • PART I

  • PART II

  • Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

  • Category I

  • Category II

  • Category III

  • Category IV

  • Category V

  • Category VI

  • Category VII

  • Category VIII

  • Category IX

  • Category X

  • Category XI

  • Category XII

  • Category XIII

  • Category XIV

  • Category XV

  • Category XVI (Males Only)

  • Category XVII (Males Only)

  • Category XVIII (Menstruating Females Only)

  • Category XIX (Menopausal Females Only)

  • PART III

  •

  • PART IV

  • Initial Consultation

  •  - -

  • Rate on a scale of 1-10:

  •
  • Should be Empty: