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Smgepqntaf04(1008).indd

Health Questionnaire (NTAF)
Name: _____________________________________Age: ______ Sex: ________ Date:
* Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.
SECTION A
• Is your memory noticeably declining? • How often do you feel you lack artistic appreciation? • Are you having a hard time remembering names • How often do you feel depressed in overcast weather? o you feel depressed in overcast weather? • How much are you losing your enthusiasm for your • Is your ability to focus noticeably declining? Is your ability to focus noticeably declining? • Has it become harder for you to learn things? • How much are you losing enjoyment for Has it become harder for you to learn things? • How often do you have a hard time remembering • How much are you losing your enjoyment of • Is your temperament getting worse in general? • Are you losing your attention span endurance? • How often do you have diffi culty falling into • How often do you fi nd yourself down or sad? • How often do you fatigue when driving compared • How often do you have feelings of dependency • How often do you fatigue when reading compared • How often do you feel more susceptible to pain? • How often do you have feelings of unprovoked anger? • How often do you walk into rooms and forget why? • How much are you losing interest in life? • How often do you pick up your cell phone and forget why? SECTION 2 - D
SECTION B
• How often do you have feelings of hopelessness? • How often do you have self-destructive thoughts? • How often do you feel that you have something that • How often do you have an inability to handle stress? • How often do you have anger and aggression while • Do you feel you never have time for yourself? Do you feel you never have time for yourself? • How often do you feel you are not getting enough • How often do you feel you are not rested even after • How often do you prefer to isolate yourself from others? • Do you think people don’t care about you? • How often do you have unexplained lack of concern for • Do you feel you are not accomplishing • How easily are you distracted from your tasks? • Do you have no one to share your problems with? • How often do you have an inability to fi nish tasks? • How often do you feel the need to consume caffeine to SECTION C
• How often do you feel your libido has been decreased? you feel your libido has been decreased? • How often do you lose your temper for minor reasons? • How often do you get irritable, shaky, or have • How often do you have feelings of worthlessness? • How often do you feel energized after eating? SECTION 3 - G
• How often do you have diffi culty eating large • How often do you feel anxious or panic for no reason? you feel anxious or panic for no reason? • How often do you have feelings of dread or • How often does your energy level drop in the afternoon? impending doom? • How often do you crave sugar and sweets in the afternoon? • How often do you feel knots in your stomach? • How often do you wake up in the middle of the night? • How often do you have feelings of being overwhelmed • How often do you have diffi culty concentrating • How often do you have feelings of guilt about • How often do you depend on coffee to keep yourself going? • How often do you feel agitated, easily upset, and nervous • How often does your mind feel restless? • How often do you have disorganized attention? o you have disorganized attention? 3
• How often do you worry about things you were • Do you crave sugar and sweets after meals? Do you crave sugar and sweets after meals? • Do you feel you need stimulants such as coffee after meals? • How often do you have feelings of inner tension and Do you feel you need stimulants such as coffee after meals? • Do you have diffi culty losing weight? • How much larger is your waist girth compared to SECTION 4 - ACH
• Do you feel your visual memory (shapes & images) • Have your thirst and appetite been increased? • Do you have weight gain when under stress? • Do you feel your verbal memory is decreased? 0 1 2 3
• Do you have diffi culty falling asleep? SECTION 1 - S
• Has your comprehension been diminished? • Are you losing your pleasure in hobbies and interests? • Do you have diffi culty calculating numbers? • How often do you feel overwhelmed with ideas to manage? • Do you have diffi culty recognizing objects & faces? • How often do you have feelings of inner rage (anger)? • Do you feel like your opinion about yourself • How often do you have feelings of paranoia? has changed? • How often do you feel sad or down for no reason? • Are you experiencing excessive urination? Are you experiencing excessive urination? • How often do you feel like you are not enjoying life?
• Are you experiencing slower mental response? Symptom groups listed in this fl yer are not intended to be used as a diagnosis of any disease condition.
All Rights Reserved. Copyright 2008, Datis Kharrazian SMGEPQNTAF04(1008).INDD
Medication History
Please circle any of the following medication you have been or are currently taking.
Acetylcholine Receptor Antagonist – Antimuscarinic Agents
Atropine, Ipratopium, Scopolamine, Tiotropium
Acetylcholine Receptor Antagonist - Ganlionic Blockers
Mecamylamine, Hexamethonium, Nicotine (high doses), Trimethaphan
Acetylcholinesterase Reactivators
Pralidoxime
Acetylcholine Receptor Antagonist - Neuromuscular Blockers
Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, Uccinylcholine, Tubocurarine,
Vecuronium, Hemicholine
Agonist Modulator of GABA Receptor (benzodiazpines)
Xanax, Lexotanil, Lexotan, Librium, Klonopin, Valium, ProSon, Rohypnol, Dalmane, Ativan, Loramet, Sedoxil, Dormicum,
Megadon, Serax , Restoril, Halcion
Agonist Modulator of GABA Receptors (nonbenzodiazpines)
Ambien, Sonata, Lunesta, Imovane
Cholinesterase Inhibitors (irreversible)
Echotiophate, Isofl urophate, Organophosphate Insecticides, Organophosphate-containing nerve agents
Cholinesterase Inhibitors (reversible)
Donepezil, Galatamine, Rivastigmine, Tacrine, THC, Erophonium, Neostigmine, Phystigimine, Pyridostigmine,
Carbamate Insecticidses
Dopamine Reuptake Inhibitors
Wellbutrin (Bupropion)
Dopamine Receptor Agonists
Mirapex, Sifrol, Requip
D2 Dopamine Receptor Blockers (antipsychotics)
Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Vesprin, Nozinan, Depixol, Navane, luanxol, Clopixol,
Acuphase, Haldol, Orap, Clozaril, Zyprexa, Zydis, Seroquel, Geodon, Solian, Invega, Abilify
GABA Antagonist Competitive binder
Flumazenil
Monoamine Oxidase Inhibitor (MAOI)
Marplan, Aurorix, Maneric, Moclodura, Nardil, Adlegiine, Elepryl, Azilect, Marsilid, Iprozid, Ipronid, Rivivol, Popilniazida, Zyvox, Zyvoxid
Noradrenergic and Specifi c Sertonergic Antidepressants (NaSSaa)
Noradrenergic and Specifi
Remeron, Zispin, Avanza, Norset, Remergil, Axit
Selective Serotonin Reuptake Inhibitor
Paxil, Zoloft, Prozac, Celexa, Lexapro, Luvox, Cipramil , Emocal, Serpam, Seropram, Cipralex, Esteria, Fontex, Seromex, Seronil,
Sarafem, Fluctin, Faverin, Seroxat, Aropax, Deroxat, Rexetin, Xentor, Paroxat, Lustral, Serlain, Dapoxetine
Selective Serotonin Reuptake Enhancers
Stablon, Coaxil, Tatinol
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Effexor, Pristiq, Meridia, Serzone, Dalcipran, Despramine, Duloxetine
Tricylic Antidepresseants (TCAs)
Elavil, Endep, Tryptanol, Trepiline, Asendin, Asendis, Defanyl, Demolox, Moxadil, Anafranil, Norpramin, Pertofrane, Prothiadin, Thanden,
Adapin, Sinequan, Trofranil, Janamine, Gamanil, Aventyl, Pamelor, Opipramol, Vivactil, Rhotrimine, Surmontil All Rights Reserved. Copyright 2008, Datis Kharrazian

Source: http://www.northparkacupuncture.com/pdf/NTAF%20form%20(1008).pdf

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U-Listed – Toxic Waste The primary hazardous properties of these materials have been indicated by the letters “T” (Toxicity), “R” (Reactivity), “I” (Ignitability) and “C” (Corrosivity). Absence of a letter indicates that the material is listed for acute toxicity only. Hazardous Acetic acid, (2,4-dichlorophenoxy)-, salts & esters Azirino[2',3' ≤ ,4]pyrrolo[1,2-a]indole

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