Please answer the following questions for yourself or your child:
|
| Yes |
No |
|
|
|
1. Do you experience mood issues, depression, or unexplained lethargy? |
|
|
2. Do you experience anxiety or nervousness? |
|
|
3. Have you been diagnosed with bipolar disorder? |
|
|
4. Have you experienced a large amount of stress at any point in your life? |
|
|
5. Are you more forgetful than you used to be, or do you have less clarity in your thinking? |
|
|
6. Do you experience headaches or migraines?
| |
|
|
7. Do you have sleep issues? |
|
|
8. Do you have problems with weight loss and or carbohydrate cravings? |
|
|
9. Do you have an eating disorder? |
|
|
10. Do you have focus issues or ADD/ADHD? |
|
|
11. Do you have a diagnosis of Autism, Aspbersger, or PDD? |
|
|
12. Are you are taking medications for the following conditions:
Anxiety
(examples of anti-anxiety medications are
Valium, Xanax, Ativan, Tofranil)
Depression or Obsesive Compulsive Disorder
(examples of anti-depressant medications are
Prozac, Lexapro, Wellbutrin, Paxil, Celexa)
Chronic Pain
(examples of pain relief medications are
Vicodin, Norco, Duragesic)
ADD/ADHD
(examples of stimulant medications are
Ritalin, Adderal, Concerta, Provigil, Strattera)
Other medications that affect brain chemistry:
(examples are: Tegretol, Lamictal, Risperdal, Amblify, Depakote)
|
|
|
13. Do you have a diagnosis of schizophrenia? |
|
|
14a. Is your child domestically or internationally adopted? |
|
|
14b. Does your child experience any of the following: night terrors, staying or falling asleep, impulsive behavior, unprovoked meltdowns or rage, irritability, defiance, or is he/she under-or-over active? |
|
Are you working with a Neurogistics Certified Practitioner?
If so, please enter his/her ID # here:
Please note that your Brain Wellness Report will be made available to your practitioner who will provide the information to you. |
Please check that you agree or disagree with the following statement: The information that I have provided in the proceeding Self Test is accurate to the best of my knowledge:
I agree I disagree |
|
