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 ---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) ---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 ---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 ---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) ---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) ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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) ---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 ---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. ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time---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 ---Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Diarrhea ---Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Constipation ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Acne ---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 ---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 ---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) ---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) ---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 ---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 ---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 ---Never - 0% of the timeRarely - less than 25% of the timeOften - half of the timeFrequently -75% of the timeAlways -100% of the time
Acne ---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 ---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 ---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 ---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 ---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 ---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 ---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 ---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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