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 Your email Your message (optional) Thank you for taking the time to review your health history. Sincerely, The Revive Team Δ