Neurotransmitter assessment Form

Thank you for attending our dinner presentation and deciding to take action to move forward and achieve your health goals.  Please fill out this neurotransmitter assessment form, as well as our patient intake form.  Be sure to submit them 24 hours before your wellness consultation, so Dr. Dae will have time to review them and create a wellness plan for you before you arrive to the office. 

We look forward to serving you and coaching you to achieve your health goal!

Name: *
Name:
Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.
SECTION A:
SECTION B:
SECTION C:
Section C1
Section C2
SECTION 1:
SECTION 2:
SECTION 3:
SECTION 4:
Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.
MEDICATION HISTORY
Please check any of the following medications you have taken in the past or are currently taking.
Noradrenergic and Specific Sertonergic Antidepressants (NaSSAas) *
Tricylic Antidepressants (TCAs) *
Selective Serotonin Reuptake Inhibitors (SSRIs) *
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) *
Selective Serotonin Reuptake Enhancers (SSREs) *
Monoamine Oxidase Inhibitors (MAOIs) *
Dopamine Receptor Agonists *
Norepinephrine and Dopamine Reuptake Inhibitors (NDRI) *
D2 Dopamine Receptor Blockers (antipsychotics) *
GABA Antagonist Competitive Binder *
Agonist Modulators of GABA Receptors (benzodiazepines) *
Agonist Modulators of GABA Receptors (non-benzodiazepines) *
Acetylcholine Receptor Agonists *
Acetylcholine Receptor Antagonists Antimuscarinic Agents *
Acetylcholine Receptor Antagonists Ganglionic Blockers *
*Please refer to prescribing physician for nutritional interactions with any medications you are taking
Acetylcholine Receptor Antagonists Neuromuscular Blockers *
Acetylcholinesterase Reactivators *
Cholinesterase Inhibitors (reversible) *
Cholinesterase Inhibitors (irreversible) *

Please also take a moment to complete the Patient Intake Form.

Thank you!