Neurotransmitter Effects Assessment
Please complete this assessment to help evaluate the effects and symptoms that may be related to neurotransmitter activity.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Are you currently taking any medications or supplements that may affect neurotransmitter levels?
*
Yes
No
Please list any relevant medications or supplements (if applicable):
In the past two weeks, how often have you experienced the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Low mood or sadness
1
2
3
4
5
Anxiety or nervousness
6
7
8
9
10
Difficulty concentrating
11
12
13
14
15
Sleep disturbances
16
17
18
19
20
Low energy or fatigue
21
22
23
24
25
Increased irritability
26
27
28
29
30
Loss of appetite or overeating
31
32
33
34
35
Cravings for sweets or carbohydrates
36
37
38
39
40
Please rate your overall mood over the past week.
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
How would you describe your stress levels during the past month?
*
Very low
Low
Moderate
High
Very high
Have you noticed any recent changes in your mood, sleep, or appetite?
*
Yes
No
If yes, please describe the changes you have noticed:
Please rate the following areas of your life as they relate to your well-being over the past month.
*
Rows
Very Poor
Poor
Average
Good
Excellent
Sleep quality
41
42
43
44
45
Ability to focus
46
47
48
49
50
Motivation
51
52
53
54
55
Overall energy
56
57
58
59
60
Ability to handle stress
61
62
63
64
65
Is there anything else you would like to share regarding your symptoms or experiences?
Submit Assessment
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