Name(*)
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Age
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Sex
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Date
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Please select 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?
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Are you having a hard time remembering names and phone numbers?
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Is your ability to focus noticeably declining?
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Has it become harder for you to learn things?
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How often do you have a hard time remembering your appointments?
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Is your temperament getting worse in general?
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Are you losing your attention span endurance?
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How often do you find yourself down or sad?
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How often do you fatigue when driving compared to the past?
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How often do you fatigue when reading compared to the past?
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How often do you walk into rooms and forget why?
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How often do you pick up your cell phone and forget why?
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Section B

How high is your stress level?
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How often do you feel that you have something that must be done?
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Do you feel you never have time for yourself?
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How often do you feel you are not getting enough sleep or rest?
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Do you find it difficult to get regular exercise?
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Do you feel uncared for by the people in your life?
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Do you feel you are not accomplishing your life’s purpose?
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Is sharing your problems with someone difficult for you?
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Section C

Section C-1

How often do you get irritable, shaky, or have lightheadedness between meals?
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How often do you feel energized after eating?
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How often do you have difficulty eating large meals in the morning?
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How often does your energy level drop in the afternoon?
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How often do you crave sugar and sweets in the afternoon?
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How often do you wake up in the middle of the night?
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How often do you have difficulty concentrating before eating?
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How often do you depend on coffee to keep yourself going?
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How often do you feel agitated, easily upset, and nervous between meals?
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Section C-2

Do you get fatigued after meals?
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Do you crave sugar and sweets after meals?
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Do you feel you need stimulants such as coffee after meals?
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Do you have difficulty losing weight?
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How much larger is your waist girth compared to your hip girth?
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How often do you urinate?
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Have your thirst and appetite been increased?
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Do you have weight gain when under stress?
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Do you have difficulty falling asleep?
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Section 1 - S

Are you losing your pleasure in hobbies and interests?
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How often do you feel overwhelmed with ideas to manage?
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How often do you have feelings of inner rage (anger)?
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How often do you have feelings of paranoia?
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How often do you feel sad or down for no reason?
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How often do you feel you lack artistic appreciation?
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How often do you feel depressed in overcast weather?
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How much are you losing your enthusiasm for your favorite activities?
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How much are you losing enjoyment for your favorite foods?
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How much are you losing your enjoyment of friendships and relationships?
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How often do you have difficulty falling into deep restful sleep?
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How often do you have feelings of dependency on others?
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How often do you feel more susceptible to pain?
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How often do you have feelings of unprovoked anger?
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How much are you losing interest in life?
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Section 2 - D

How often do you have feelings of hopelessness?
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How often do you have self-destructive thoughts?
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How often do you have an inability to handle stress?
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How often do you have anger and aggression while under stress?
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How often do you feel you are not rested even after long hours of sleep?
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How often do you prefer to isolate yourself from others?
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How often do you have unexplained lack of concern for family and friends?
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How easily are you distracted from your tasks?
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How often do you have an inability to finish tasks?
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How often do you feel the need to consume caffeine to stay alert?
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How often do you feel your libido has been decreased?
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How often do you have feelings of worthlessness?
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Section 3 - G

How often do you feel anxious or panic for no reason?
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How often do you have feelings of dread or impending doom?
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How often do you feel knots in your stomach?
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How often do you have feelings of being overwhelmed for no reason?
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How often do you have feelings of guilt about everyday decisions?
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How often does your mind feel restless?
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How difficult is it to turn your mind off when you want to relax?
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How often do you have disorganized attention?
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How often do you worry about things you were not worried about before?
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How often do you have feelings of inner tension and inner excitability?
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Section 4 - ACH

Do you feel your visual memory (shapes & images) is decreased?
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Do you feel your verbal memory is decreased?
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Do you have memory lapses?
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Has your creativity been decreased?
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Has your comprehension been diminished?
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Do you have difficulty calculating numbers?
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Do you have difficulty recognizing objects & faces?
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Are you experiencing excessive urination?
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Are you experiencing slower mental response?
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Medication History

Please check any of the following medications you have been or are currently taking.

Acetylcholine Receptor Antagonist – Antimuscarinic Agents
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Acetylcholine Receptor Antagonist - Ganlionic Blockers
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Acetylcholinesterase Reactivators
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Acetylcholine Receptor Antagonist - Neuromuscular Blockers
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Agonist Modulator of GABA Receptor (benzodiazepines)
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Agonist Modulator of GABA Receptors (nonbenzodiazepines)
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Cholinesterase Inhibitors (irreversible)
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Cholinesterase Inhibitors (reversible)
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Dopamine Reuptake Inhibitors
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Dopamine Receptor Agonists
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GABA Antagonist Competitive binder
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Monoamine Oxidase Inhibitors (MAOI)
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Noradrenergic and Specific Sertonergic Antidepressants (NaSSaa)
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Selective Serotonin Reuptake Inhibitors
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Selective Serotonin Reuptake Enhancers
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Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
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Tricylic Antidepressants (TCAs)
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Please list any medication you are currently taking not listed above and how long you have been taking it
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Please list any medications you have taken in the past, when did you take them and for how long
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