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Health Questionnaire (NTAF)
Name: _____________________________________Age: ______ Sex: ________ Date:______________________
* Please circle 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? • How often do you feel you lack artistic appreciation? • Are you having a hard time remembering names • How often do you feel depressed in overcast weather? • How much are you losing your enthusiasm for your • Is your ability to focus noticeably declining? • Has it become harder for you to learn things? • How much are you losing enjoyment for • How often do you have a hard time remembering • How much are you losing your enjoyment of • Is your temperament getting worse in general? 0 1 2 3 friendships and relationships?
• Are you losing your attention span endurance? • How often do you have difficulty falling into • How often do you find yourself down or sad? • How often do you fatigue when driving compared • How often do you have feelings of dependency • How often do you fatigue when reading compared • How often do you feel more susceptible to pain? • How often do you have feelings of unprovoked anger? 0 1 2 3
• How often do you walk into rooms and forget why? • How much are you losing interest in life? • How often do you pick up your cell phone and forget why? SECTION 2 - D
SECTION B
• How often do you have feelings of hopelessness? • How often do you have self-destructive thoughts? • How often do you feel that you have something that • How often do you have an inability to handle stress? • How often do you have anger and aggression while • Do you feel you never have time for yourself? • How often do you feel you are not getting enough • How often do you feel you are not rested even after • Do you find it difficult to get regular exercise? • How often do you prefer to isolate yourself from others? • Do you feel uncared for by the people in your life? • How often do you have unexplained lack of concern for • Do you feel you are not accomplishing your • How easily are you distracted from your tasks? • Is sharing your problems with someone difficult for you? 0 1 2 3
• How often do you have an inability to finish tasks? • How often do you feel the need to consume caffeine to SECTION C
• How often do you feel your libido has been decreased? • How often do you lose your temper for minor reasons? 0 1 2 3
• How often do you get irritable, shaky, or have • How often do you have feelings of worthlessness? • How often do you feel energized after eating? SECTION 3 - G
• How often do you have difficulty eating large • How often do you feel anxious or panic for no reason? • How often do you have feelings of dread or • How often does your energy level drop in the afternoon? 0 1 2 3 impending doom?
• How often do you crave sugar and sweets in the afternoon? • How often do you feel knots in your stomach? • How often do you wake up in the middle of the night? • How often do you have feelings of being overwhelmed • How often do you have difficulty concentrating • How often do you have feelings of guilt about • How often do you depend on coffee to keep yourself going? 0 1 2 3
• How often do you feel agitated, easily upset, and nervous • How often does your mind feel restless? • How difficult is it to turn your mind off when you • How often do you have disorganized attention? • How often do you worry about things you were • Do you crave sugar and sweets after meals? • Do you feel you need stimulants such as coffee after meals? • How often do you have feelings of inner tension and • Do you have difficulty losing weight? • How much larger is your waist girth compared to SECTION 4 - ACH
• Do you feel your visual memory (shapes & images) • Have your thirst and appetite been increased? • Do you have weight gain when under stress? • Do you feel your verbal memory is decreased? • Do you have difficulty falling asleep? 0 1 2 3
• Has your creativity been decreased? 0 1 2 3
SECTION 1 - S
• Has your comprehension been diminished? • Are you losing your pleasure in hobbies and interests? • Do you have difficulty calculating numbers? • How often do you feel overwhelmed with ideas to manage? 0 1 2 3 • Do you have difficulty recognizing objects & faces?
• How often do you have feelings of inner rage (anger)? • Do you feel like your opinion about yourself • How often do you have feelings of paranoia? 0 1 2 3 has changed?
• How often do you feel sad or down for no reason? • Are you experiencing excessive urination? • How often do you feel like you are not enjoying life? • Are you experiencing slower mental response? Symptom groups listed in this flyer are not intended to be used as a diagnosis of any disease condition.
All Rights Reserved. Copyright 2009, Datis Kharrazian Medication History*
Please check any of the following medications 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
Acetylcholine Receptor Antagonist - Neuromuscular Blockers
Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, Succinylcholine, Tubocurarine, Agonist Modulator of GABA Receptor (benzodiazepines)
Xanax®, Lexotanil, Lexotan®, Librium, Klonopin®, Valium®, ProSom®, Rohypnol, Dalmane, Ativan, Loramet®, Sedoxil, Dormicum, Megalodon, Serax®, Restoril, Halcion Agonist Modulator of GABA Receptors (nonbenzodiazepines)
Ambien CR®, Sonata®, Lunesta®, Imovane Cholinesterase Inhibitors (irreversible)
Echotiophate, Isoflurophate, Organophosphate Insecticides, Organophosphate-containing nerve agents Cholinesterase Inhibitors (reversible)
Donepezil, Galatamine, Rivastigmine, Tacrine, THC, Edrophonium, Neostigmine, Physostigmine, Pyridostigmine, Carbamate Insecticides Dopamine Reuptake Inhibitors
Dopamine Receptor Agonists
D2 Dopamine Receptor Blockers (antipsychotics)
Thorazine®, Prolixin®, Trilafon®, Compazine®, Mellaril®, Stelazine®, Vesprin®, Nozinan®, Depixol®, Navane®, Fluanxol®, Clopixol®, Acuphase®, Haldol®, Orap®, Clozaril®, Zyprexa®, Zydis®, Seroquel XR®, Geodon®, Solian®, Invega®, Abilify® GABA Antagonist Competitive binder
Monoamine
® Oxidase Inhibitors (MAOI)
Marplan®, Aurorix®, Manerix®, Moclodura, Nardil, Adeline®, Eldepryl®, Azilect®, Marsilid®, Iprozid®, Ipronid®, Rivivol, Popilniazida®, Zyvox®, Zyvoxid® Noradrenergic
® and Specific Sertonergic
® Antidepressants (NaSSaa)
Remeron®, Zispin®, Avanza®, Norset®, Remergil®, Axit® Selective Serotonin Reuptake Inhibitors
Paxil®, Zoloft®, Prozac®, Celexa®, Lexapro®, Luvox®, Cipramil®, Emocal®, Seropram®, Cipralex®, Esteria®, Fontex®, Dapoxetine® Seromex®, Seronil®, Sarafem®, Fluctin®, Faverin®, Seroxat, Aropax®, Deroxat®, Rexetin®, Paroxat®, Lustral®, Serlain® Selective Serotonin Reuptake Enhancers
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Effexor®, Pristiq®, Meridia, Serzone®, Dalcipran®, Despiramin, Duloxetine Tricylic Antidepressants (TCAs)
Elavil®, Endep®, Tryptanol, Trepiline®, Asendin®, Asendis®, Defanyl®, Demolox®, Moxadil®, Anafranil®, Norpramin®, Pertofrane®, Prothiaden®, Adapin®, Sinequan®, Tofranil®, Janamine®, Gamanil®, Aventyl®, Pamelor®, Opipramol®, Vivactil®, Rhotrimine®, Surmontil® *Please refer to prescribing physician for nutritional interactions with any medications you may be taking.
All Rights Reserved. Copyright 2009, Datis Kharrazian
SMGENTAF04(031511)

Source: http://www.drgoldwellness.com/wp-content/uploads/NT_form.pdf

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