Contact Us
About
Overview
Dixie Wall
Amanda Aumiller
Health Services
Nutritional Consult / Lab Review
Neuro-Emotional Technique (NET)
Acupuncture
What is Acupuncture?
How Does Acupuncture Work?
Weight Loss
Nambudripad’s Allergy Elimination Techniques
Cupping
Addiction
Healthy Products
Workshops & Groups
Forms
Blog
Life Tips
Recipes
Healthy Remedies
Contact
About
Overview
Dixie Wall
Amanda Aumiller
Health Services
Nutritional Consult / Lab Review
Neuro-Emotional Technique (NET)
Acupuncture
What is Acupuncture?
How Does Acupuncture Work?
Weight Loss
Nambudripad’s Allergy Elimination Techniques
Cupping
Addiction
Healthy Products
Workshops & Groups
Forms
Blog
Life Tips
Recipes
Healthy Remedies
Contact
Name
(*)
Invalid Input
Age
Invalid Input
Sex
Invalid Input
Date
Invalid Input
Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.
Section 1
A decrease in attention span
0
1
2
3
Invalid Input
Mental fatigue
0
1
2
3
Invalid Input
Difficulty learning new things
0
1
2
3
Invalid Input
Difficulty staying focused and concentrating for extended periods of time
0
1
2
3
Invalid Input
Experiencing fatigue when reading sooner than in the past
0
1
2
3
Invalid Input
Experiencing fatigue when driving sooner than in the past
0
1
2
3
Invalid Input
Need for caffeine to stay mentally alert
0
1
2
3
Invalid Input
Overall brain function impairs your daily life
0
1
2
3
Invalid Input
Section 2
Twitching or tremor in your hands and legs when resting
0
1
2
3
Invalid Input
Handwriting has gotten smaller and more crowded together
0
1
2
3
Invalid Input
A loss of smell to foods
0
1
2
3
Invalid Input
Stiffness in shoulders and hips that goes away when you start to move
0
1
2
3
Invalid Input
Constipation
0
1
2
3
Invalid Input
Voice has become softer
0
1
2
3
Invalid Input
Facial expression that is serious or angry
0
1
2
3
Invalid Input
Episodes of dizziness or light-headedness upon standing
0
1
2
3
Invalid Input
A hunched over posture when getting up and walking
0
1
2
3
Invalid Input
Section 3
Memory loss that impacts daily activities
0
1
2
3
Invalid Input
Difficulty planning, problem solving, or working with numbers
0
1
2
3
Invalid Input
Difficulty completing daily tasks
0
1
2
3
Invalid Input
Confusion about dates, the passage of time, or place
0
1
2
3
Invalid Input
Difficulty understanding visual images and spatial relationships (addresses and locations)
0
1
2
3
Invalid Input
Difficulty finding words when speaking
0
1
2
3
Invalid Input
Misplacement of things and inability to retrace steps
0
1
2
3
Invalid Input
Poor judgement and bad decisions
0
1
2
3
Invalid Input
Disinterest in hobbies, social activities, or work
0
1
2
3
Invalid Input
Personality or mood changes
0
1
2
3
Invalid Input
Section 4
Reduced function in overall hearing
0
1
2
3
Invalid Input
Difficulty understanding language with background or scatter noise
0
1
2
3
Invalid Input
Ringing or buzzing in the ear
0
1
2
3
Invalid Input
Difficulty comprehending language without perfect pronunciation
0
1
2
3
Invalid Input
Difficulty recognizing familiar faces
0
1
2
3
Invalid Input
Changes in comprehending the meaning of sentences, written or spoken
0
1
2
3
Invalid Input
Difficulty with verbal memory and finding words
0
1
2
3
Invalid Input
Difficulty remembering events
0
1
2
3
Invalid Input
Difficulty recalling previously learned facts and names
0
1
2
3
Invalid Input
Inability to comprehend familiar words when read
0
1
2
3
Invalid Input
Difficulty spelling familiar words
0
1
2
3
Invalid Input
Monotone, unemotional speech
0
1
2
3
Invalid Input
Difficulty understanding the emotions of others when they speak (nonverbal cues)
0
1
2
3
Invalid Input
Disinterest in music and a lack of appreciation for melodies
0
1
2
3
Invalid Input
Difficulty with long-term memory
0
1
2
3
Invalid Input
Memory impairment when doing the basic activities of daily living
0
1
2
3
Invalid Input
Difficulty with directions and visual memory
0
1
2
3
Invalid Input
Noticeable differences in energy levels throughout the day
0
1
2
3
Invalid Input
Section 5
Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach for objects.
0
1
2
3
Invalid Input
Difficulty comprehending written text
0
1
2
3
Invalid Input
Floaters or halos in your visual field
0
1
2
3
Invalid Input
Dullness of colors in your visual field during different times of the day
0
1
2
3
Invalid Input
Difficulty discriminating similar shades of color
0
1
2
3
Invalid Input
Section 6
Difficulty with detailed hand coordination
0
1
2
3
Invalid Input
Difficulty with suppressing socially inappropriate thoughts
0
1
2
3
Invalid Input
Socially inappropriate behavior
0
1
2
3
Invalid Input
Decisions made based on desires, regardless of the consequences
0
1
2
3
Invalid Input
Difficulty motivating yourself to start and finish tasks
0
1
2
3
Invalid Input
A loss of attention and concentration
0
1
2
3
Invalid Input
Section 7
Hypersensitivities to touch or pain
0
1
2
3
Invalid Input
Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall
0
1
2
3
Invalid Input
Frequently bumping into the wall or objects
0
1
2
3
Invalid Input
Difficulty with right-left discrimination
0
1
2
3
Invalid Input
Handwriting has become sloppier
0
1
2
3
Invalid Input
Difficulty with basic math calculations
0
1
2
3
Invalid Input
Difficulty finding words for written or verbal communication
0
1
2
3
Invalid Input
Difficulty finding words for written or verbal communication
0
1
2
3
Invalid Input
Section 8
Difficulty swallowing supplements or large bites of food
0
1
2
3
Invalid Input
Bowel motility and movements slow
0
1
2
3
Invalid Input
Bloating after meals
0
1
2
3
Invalid Input
Dry eyes or dry mouth
0
1
2
3
Invalid Input
A racing heart
0
1
2
3
Invalid Input
A flutter in the chest or an abnormal heart rhythm
0
1
2
3
Invalid Input
Bowel or bladder incontinence resulting in staining your underwear
0
1
2
3
Invalid Input
Section 9
A decrease in movement speed
0
1
2
3
Invalid Input
Difficulty initiating movement
0
1
2
3
Invalid Input
Stiffness in your muscles (not joints)
0
1
2
3
Invalid Input
A stooped posture when walking
0
1
2
3
Invalid Input
Cramping of your hand when writing
0
1
2
3
Invalid Input
Section 10
Abnormal body movements (such as twitching legs)
0
1
2
3
Invalid Input
Desires to flinch, clear your throat, or perform some type of movement
0
1
2
3
Invalid Input
Constant nervousness and a restless mind
0
1
2
3
Invalid Input
Compulsive behaviors
0
1
2
3
Invalid Input
Increased tightness and tone in specific muscles
0
1
2
3
Invalid Input
Section 11
Difficulty with balance, or balance that is noticeably worse on one side
0
1
2
3
Invalid Input
A need to hold the handrail or watch each step carefully when going down stairs
0
1
2
3
Invalid Input
Episodes of dizziness
0
1
2
3
Invalid Input
Nausea, car sickness, or seasickness
0
1
2
3
Invalid Input
A quick impact after consuming alcohol
0
1
2
3
Invalid Input
A slight hand shake when reaching for something
0
1
2
3
Invalid Input
Back muscles that tire quickly when standing or walking
0
1
2
3
Invalid Input
Chronic neck or back muscle tightness
0
1
2
3
Invalid Input
Submit
Enter Your Email and We'll Send you Recipes, Holistic Health Advice, Weight Loss Tips, and More!
Copyright © 2019 Acuworks Health. All Rights Reserved.
Privacy Policy
Terms of Use
Site Map
×
Log in
Username
Password
Log in
Forgot your password?
Forgot your username?
