MF - Neurotransmitter Assessment Form™- NTAF - CMIE

MF – Neurotransmitter Assessment Form™- NTAF

Step 1 of 11 – Informations personnelles

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

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Date of birth(Required)

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	0	1	2	3
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 new things?
How often do you have a hard time remembering your appointments?
Is your temperament generally getting worse?
Is your attention span decreasing?
How often do you find yourself down or sad?
How often do you become fatigued when driving compared to in the past?
How often do you become fatigued when reading compared to in the past?
How often do you walk into rooms and forget why?
How often do you pick up your cell phone and forget why?

	0	1	2	3
How high is your stress level?
How often do you feel 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?

	0	1	2	3
How often do you get irritable, shaky, or have light-headedness between meals?
How often do you feel energized after eating?
How often do you have difficulty 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?

	0	1	2	3
How often do you get fatigued after meals?
How often do you crave sugar and sweets after meals?
How often do you feel you need stimulants, such as coffee, after meals?
How often 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 increased?
How often do you gain weight when under stress?
How often do you have difficulty falling asleep?

	0	1	2	3
Are you losing interest in hobbies?
How often do you feel overwhelmed?
How often do you have feelings of inner rage?
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 your 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?

	0	1	2	3
A decrease in mental alertness
A decrease in mental speed
A decrease in concentration quality
Slow cognitive processing
Impaired mental performance
An increase in the ability to be distracted
Need coffee or caffeine sources to improve mental function