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
• 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
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
Prescription Program Formulary — To be used by members who have a formulary drug plan. Anthem Blue Cross and Blue Shield prescription drug benefits include medications available on the Anthem Drug List/Formulary. Our prescription drug benefits can • If you have additional offer potential savings when your physician prescribes medications on the drug list/formulary. questi