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