Bayareathyroidcenter.com

Neurotransmitter Assessment Form (NTAF)
Name: _____________________________________Age: ______ Sex: ________ Date:______________________
Please circle the appropriate number 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? • How much are you losing your enthusiasm for your • Is your ability to focus noticeably declining? • Has it become harder for you to learn new things? • How much are you losing your enjoyment for • How often do you have a hard time remembering • How much are you losing your enjoyment of • Is your temperament generally getting worse? • How often do you have difficulty falling into • How often do you find yourself down or sad? • How often do you become fatigued when driving • How often do you have feelings of dependency • How often do you become fatigued when reading • 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
SECTION B
• How often do you have feelings of hopelessness? • How often do you have self-destructive thoughts? • How often do you feel 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? • How often do you feel you are not getting enough • How often do you feel you are not rested, even after • Do you find it difficult to get regular exercise? • How often do you prefer to isolate yourself from others? • Do you feel uncared for by the people in your life? • How often do you have unexplained lack of concern for • Do you feel you are not accomplishing your • How easily are you distracted from your tasks? • Is sharing your problems with someone difficult for you? • How often do you have an inability to finish tasks? • How often do you feel the need to consume caffeine to SECTION C
• How often do 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
• How often do you have difficulty eating large • How often do you feel anxious or panicked for no reason? 0 1 2 3
• How often do you have feelings of dread or • How often does your energy level drop in the afternoon? • 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 difficulty 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 difficult is it to turn your mind off when you • How often do you get fatigued after meals? • How often do you have disorganized attention? • How often do you crave sugar and sweets after meals? • How often do you worry about things you were • How often do you feel you need stimulants, such as • How often do you have feelings of inner tension and • How often do you have difficulty losing weight? • How much larger is your waist girth compared to your hip girth? SECTION 4
• Do you feel your visual memory (shapes & images) • Have your thirst and appetite increased? • How often do you gain weight when under stress? • Do you feel your verbal memory has decreased? • How often do you have difficulty falling asleep? SECTION 1
• Do you have difficulty calculating numbers? • Do you have difficulty recognizing objects & faces? • How often do you have feelings of inner rage? • Do you feel like your opinion about yourself • How often do you have feelings of paranoia? • How often do you feel sad or down for no reason? • Are you experiencing excessive urination? • How often do you feel like you are not enjoying life? • Are you experiencing a slower mental response? Copyright 2011, Datis Kharrazian. All Rights Reserved. Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition. SMGENTAF04(110211)
Medication History*
Please check any of the following medications you have taken in the past or are currently taking.
Noradrenergic and Specific Sertonergic
Monoamine Oxidase Inhibitors (MAOIs)
Agonist Modulators of GABA Receptors
Antidepressants (NaSSAas)
(nonbenzodiazepines)
Tricylic Antidepressants (TCAs)
Acetylcholine Receptor Antagonists
Antimuscarinic Agents
Dopamine Receptor Agonists
Acetylcholine Receptor Antagonists
Norepinephrine and Dopamine
Ganglionic Blockers
Reuptake Inhibitors (NDRI)
D2 Dopamine Receptor Blockers
(antipsychotics)
Selective Serotonin
Reuptake Inhibitors (SSRIs)
Acetylcholine Receptor Antagonists
Neuromuscular Blockers
Acetylcholinesterase Reactivators
GABA Antagonist Competitive Binder
Cholinesterase Inhibitors (reversible)
Serotonin-Norepinephrine
Reuptake Inhibitors (SNRIs)
Agonist Modulators of GABA Receptors
(benzodiazepines)
Cholinesterase Inhibitors (irreversible)
Selective Serotonin
Reuptake Enhancers (SSREs)
 Organophosphate-containing nerve agents *Please refer to prescribing physician for nutritional interactions with any medications you are taking. Copyright 2011, Datis Kharrazian. All Rights Reserved.
SMGENTAF04(110211)

Source: http://www.bayareathyroidcenter.com/docs/NTAF-Form.pdf