Neurological Intake Form

Today's date:
Your first name:
Last name:
Date of Birth:

For each of the following questions, please select the choice that best applies to you. Please respond to each and every question. Thank you.

Frontal Lobe Prefrontal, Dorsolateral and Orbitofrontal (Areas 9, 10, 11 & 12)

Difficulty with restraint and controlling impulses or desires —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Emotional instability (lability) —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty planning and organizing —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty making decisions —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Lack of motivation enthusiasm, interest and drive (apathetic) —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty getting a sound or melody out of your thoughts (perseveration) —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Constantly repeat events or thoughts with difficulty letting go —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty initiating and finishing tasks —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Episodes of depression —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Mental fatigue —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Decrease in attention span —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty staying focused and concentrating for extended periods of time —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty with creativity, imagination and intuition —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty in appreciating art and music —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty with analytical thought —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty taking ideas, actions, and words and putting them in a linear sequence —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Frontal Lobe Precentral and Supplementary Motor Area (Areas 4 & 6)
Initiating movements with your arm or leg has become more difficult —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Feeling of arm or leg heaviness, especially when tired —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Increased muscle tightness in your arm or leg —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Reduced muscle endurance in your arm or leg —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Noticeable difference in your muscle function or strength from one side to the other —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Noticeable difference in your muscle tightness from one side to the other —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Frontal Lobe Broca's Motor Speech Area (Areas 44 & 45)
Difficulty producing words verbally, especially when fatigued —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Find the actual act of speaking difficult at times —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Notice word pronunciation and speaking fluency change at times —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3, 1, 2 & 7)
Difficulty in perceptions of position of limbs —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Frequently bumping body or limbs into the wall or objects accidentally —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Recurring injury in the same body part or side of the body —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Hypersensitivities to touch or pain perception —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Parietal Inferior Lobule (Areas 39 & 40)
Confusion of Right/Left —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty with math calculations —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty finding words —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty with writing —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty recognizing symbols or shapes —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty with simple drawings —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty interpreting maps —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Temporal Lobe Auditory Cortex (Areas 41 & 42)
Reduced function in overall hearing —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty interpreting speech with background or scatter noise —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty comprehending language without perfect pronunciation —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Need to look at someone's mouth when they are speaking to understand what they are saying —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty in localizing sound —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Noticeable ear preference when using your phone —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Temporal Lobe Auditory Association Cortex (Area 22)
Difficulty comprehending meaning of spoken word —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Tend toward monotone speech without fluctuations or emotions —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Medial Temporal Lobe and Hippocampus
Memory less efficient —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Memory loss that impacts daily activities —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Confusion about dates, the passage of time, or place —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty remembering events —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Misplacement of things and difficulty retracing steps —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty with memory of locations (addresses) —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty with visual memory —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Forgetting where you put items such as keys, wallet, phone, etc. —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty remembering faces —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty remembering to stay or be on time —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Occipital Lobe (Area 17, 18 & 19)
Difficulty in discriminating similar shades of color —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Dullness of colors in visual field —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach out for objects —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Floaters or halos in visual field —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Cerebellum - Spinocerebellum
Difficulty with balance, or balance that is worse on one side —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
A need to hold the handrail or watch each step carefully when going down stairs —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Feeling unsteady and prone to falling in the dark —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Prone to sway to one side when walking or standing —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Cerebellum - Cerebrocerebellum
Recent clumsiness in hands —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Recent clumsiness in feet or frequent tripping —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
A slight hand shake when reaching for something at the end of movement —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Cerebellum - Vestibulocerebellum
Episodes of dizziness or disorientation —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Back muscles that tire quickly when standing or walking —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Chronic neck or back muscle tightness —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Nausea, car sickness, or sea sickness —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Feeling of disorientation or shifting of the environment —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Crowded places cause anxiety —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Basal Ganglia Direct Pathway
Slowness in movements —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Stiffness in your muscles (not joints) that goes away when you move —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Cramping of hands when writing —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
A stooped posture when walking —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Voice has become softer —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Facial expressions changed leading people to frequently ask if you are upset or angry —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Basal Ganglia Indirect Pathway
Uncontrollable muscle movements —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Intense need to clear your throat regularly or contract a group of muscles —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Obsessive compulsive tendencies —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Constant nervousness and restless mind —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Autonomic Reduced Parasympathetic Activity
Voice has become softer —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Dry mouth or eyes —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty swallowing supplements or large bites of food —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Autonomic Increased Sympathetic Activity
Tendency for anxiety —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Easily startled —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty relaxing —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Sensitive to bright or flashing lights —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Episodes of racing heart —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty sleeping —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Epileptiform Activity
Have you ever been diagnosed with a seizure disorder? YesNo
Have you ever been diagnosed with epilepsy? YesNo
Have you ever been told that you seemed frozen, absent, or tuned out at times without any recollection of the event? YesNo
Have you ever experienced sudden muscle stiffness and rigidity throughout your body? YesNo
Have you ever experienced a total loss of your muscle tone that led to loss of control of your muscles or fall? YesNo
Have you ever been told that you stare into space while you're lip smacking, chewing or fidgeting--that you are aware of? YesNo
Do you ever experience sudden emotional responses such as anxiety, sadness, cry, or laugh for no reason? YesNo
Do you ever experience sudden involuntary muscle contractures or jerks in any individual parts of your limbs or face? YesNo
Do you ever experience sudden involuntary head rotation and your eyes move forcefully to one side? YesNo
Do you ever experience a sudden involuntary shift in your eyes to the side or upwards? YesNo
Do you ever experience a sudden vocalization of random words or notice a sudden inability to speak? YesNo
Do you ever experience any spontaneous sensations of tingling, "pins and needles" numbness, coldness, burning or other random sensations in any region of your body? YesNo
Do you experience a ringing sensation in your ears (tinnitus,) sounds or voices spontaneously? YesNo
Do you ever experience spontaneous perception of smells such as burning rubber, foul smells, or other odors without finding the source of the odor? YesNo
Do you ever experience flashing lights, stars, or jagged lines in your visual field? YesNo

Metabolic Review
Feeling that bowels do not empty completely —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time—Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Lower abdominal pain relieved by passing stool or gas —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Diarrhea —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Constipation —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
More than three bowel movements daily —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Use laxatives frequently —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Excessive belching, burping or bloating —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Gas immediately following a meal —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Offensive breath —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Sense of fullness during and after meals —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty digesting fruits and vegetables; undigested foods found in stools —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Stomach pain, burning or aching 1 to 4 hours after eating —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Use antacids —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Feel hungry an hour or two after eating —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Heartburn when lying or bending forward —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Temporary relief by using antacids, food, milk or carbonated beverages —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Digestive problems subside with rest and relaxation —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol and caffeine —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Indigestion and fullness last 2 to 4 hours after eating —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Pain, tenderness, soreness on left side under the rib cage —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Nausea and/or vomiting —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Frequent urination —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Increased thirst and appetite —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficulty losing weight —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Greasy or high fat foods cause distress —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Lower bowel gas and/or bloating several hours after eating —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Bitter metallic taste in mouth, especially in the morning —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Unexplained itchy skin —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Yellow cast to eyes —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Stool color alternates from clay colored to normal brown —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Reddened skin, especially palms —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Dry or flaky skin and/or hair —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
History of gallbladder attacks or stones —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Have you had your gallbladder removed? YesNo
Crave sweets during the day —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Eating sweets does not relieve cravings for sugar —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Irritable if meals are missed —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Depend on coffee to keep going/getting started —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Get light-headed if meals are missed —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Eating relieves fatigue —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Fatigue after meals —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Crave sweets after meals —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Waist girth is equal to or larger than hip girth? YesNo
Crave salt —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Afternoon fatigue —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Dizziness when standing up quickly —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Afternoon headaches —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Headaches with exertion and stress —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Weak nails —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Excessive perspiration or perspiration with little or no activity —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Feel cold--hands, feet, all over —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Difficult, infrequent bowel movements —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Depression/lack of motivation —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Morning headaches that wear off as the day progresses —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Outer third of eyebrow thins —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Thinning of hair on scalp, face, or genitals; excessive hair loss —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Dryness of skin and/or scalp —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Mental sluggishness —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Heart palpitations —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Inward trembling —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Night sweats —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Diminished sex drive —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Increased sex drive —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Urination difficulty or dribbling —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Pain inside legs or heels —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Feeling of incomplete emptying —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Leg twitching at night —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Metabolic Review--Male Patients
Decreased number of spontaneous erections —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Decreased fullness of erections —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

Metabolic Review--Female Patients
Decreased physical stamina —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Acne —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Painful intercourse —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Decreased physical stamina —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Premenopausal? YesNo
Extended menstrual cycle (greater than every 32 days) —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Shortened menstrual cycle (less than every 24 days) —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Pain and cramping during menses —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Pelvic pain during menses —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Irritable and depressed during menses —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Acne —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Facial hair growth —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
How many years have you been menopausal —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Since menopause, do you have any uterine bleeding —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Hot flashes —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Painful intercourse —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Shrinking breasts —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Vaginal pain, dryness or itching —Please choose an option—Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time

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Thank you for taking the time to review your health history.
Sincerely,
The Revive Team

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