Neurotransmitter Imbalance Questionnaire

The questionnaire below is designed to determine if you may have a depletion in your neurotransmitter levels. It is based on the work of Julia Ross, MA. This is only a guide. For a more accurate way of determining an imbalance, a neurotransmitter test is available.

The results from your questionnaire can help guide you in making treatment decisions. Supplement recommendations are provided at the end of each section. If you have scored positive for more than one imbalance, you would need to take supplements from both sections, and you could worsen the imbalance by correcting only one area. The inhibitory and excitatory systems must be in balance. Again, to obtain a more accurate picture of your brain chemistry, Neurotransmitter lab testing should be considered.

Find out more about the Neurotransmitter Tests we have available.

This questionnaire is not intended to be a substitute for diagnosis by a qualified mental healthcare provider. If you do not have access to one in your area, we offer telephone consultations with our licensed nurse practitioner or doctor. Please call (941) 371-7997 to schedule an appointment.

Instructions: For all the questions you answered YES to, add up the points at the end of each section. If your score totals more than the amount listed at the end of each section, consider trying the supplements listed to correct that particular imbalance.

If you score shows a possible neurotransmitter imbalance, consider taking a neurotransmitter lab test for more conclusive information.

If you score revealed a combination of neurotransmitter depletions, then take:

Brain Balance: Brain Balance helps to increase levels of Serotonin, Dopamine, Epinephrine, Norepinephrine, and GABA. Take two capsules twice a day.

Part 1. Are You Under a Dark Cloud?

Points

3 Do you have a tendency to be negative, to see the glass as half-empty rather than half-full? Do you have dark, pessimistic thoughts?

3 Are you often worried and anxious?

3 Do you have feelings of low self-esteem and lack confidence? Do you easily get to feeling self-critical and guilty?

3 Does your behavior often get a bit, or a lot, obsessive? Is it hard for you to make transitions, to be flexible? Are you a perfectionist, a neatnik, or a control freak? A computer, TV, or work addict?

3 Do you really dislike the dark weather or have a clear-cut fall/winter depression (SAD)?

2 Are you apt to be irritable, impatient, edgy, or angry?

3 Do you tend to be shy or fearful? Do you get nervous or panicky about heights, flying, enclosed spaces, public performance, spiders, snakes, bridges, crowds, leaving the house, or anything else?

2 Have you had anxiety attacks or panic attacks (your heart races, it’s hard to breathe)?

2 Do you get PMS or menopausal moodiness (tears, anger, depression)?

3 Do you hate hot weather?

2 Are you a night owl, or do you often find it hard to get to sleep, even though you want to?

2 Do you wake up in the night, have restless or light sleep, or wake up too early in the morning?

3 Do you routinely like to have sweet or starchy snacks, wine, or marijuana in the afternoons, evenings, or in the middle of the night (but not earlier in the day)?

2 Do you find relief from any of the above symptoms through exercise?

3 Have you had fibromyalgia (unexplained muscle pain) or TMJ (pain, tension, and grinding associated with your jaw)?

2 Have you had suicidal thoughts or plans?

Total Score ____________ If your score is more than 12 then you are probably experiencing symptoms of low serotonin. Serotonin is an inhibitory neurotransmitter. Depletion of the inhibitory neurotransmitters are the most common cause of depression and anxiety.

Serotonin Supplements



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