test-form Amino Acid Therapy Chart for Balancing Brain Chemistry Your name Your email Please follow the directions below ------------------------------------------------------------------------------------------------------------ Type 1: Serotonin: emotional flexibility, self-confidence, optimism, sense of humor. Melatonin: (made from serotonin) good sleep Please answer the number 0 to 10 that best matches how you currently experience each symptom using the following scale for all questions…. 0 = Not experienced at all 1 = Felt slightly or infrequently – then any number as appropriate through to 10 = Unbearable or All the timeNegativity, depression Winter Blues Worry, Anxiety Low Self Esteem Hyperactivity Obsessive compulsive thoughts/behaviors Perfectionist, controlling Irritiability, Rage, PMS Panic, Phobias (Fear or snakes, small spaces, social, etc) Fibromyalgia, TMJ. Migraines Afternoon or evening cravings of substances Insomnia, disturbed sleep Night owl, hard to get to sleep Suicidal Thoughts Benefit from SSRI's Positive Outlook ------------------------------------- Serotonin and Melatonin (5-HTP, L-Tyrptophan, Melatonin) Please place a check in the correct column. (Even if you have used it one time please place check in the correct column).Chocolate Currently UsePast UseNever Use Sweets Currently UsePast UseNever Use Starch Currently UsePast UseNever Use Alcohol Currently UsePast UseNever Use Ecstacy Currently UsePast UseNever Use Marijuana Currently UsePast UseNever Use Tobacco Currently UsePast UseNever Use Celaxa / Citalopram Currently UsePast UseNever Use Effexor / Venlofaxine Currently UsePast UseNever Use Lexapor / Escitalopram Currently UsePast UseNever Use Paxil / Paroxetine Currently UsePast UseNever Use Prozac / Fluoxetine Currently UsePast UseNever Use Trazodone Currently UsePast UseNever Use Zoloft / Sertraline Currently UsePast UseNever Use other SSRI Medication Currently UsePast UseNever Use------------------------------------------------------------------------------------------------------------ Type 2: Catecholamines: Alertness, energy, mental focus, drive, enthusiasm. 0 = Not experienced at all | 1 = Felt slightly or infrequently – then any number as appropriate through to 10 = Unbearable or All the time. Apathetic depression Lack of energy Easily bored Lack of drive Lack of focus/concentration ADD (attention deficit disorder) Crave substances for energy or focus ADHD------------------------------------- Catecholamines (L-Tyrosine, L-Phenylalanine, L-Dopa) Please place a check in the correct column. (Even if you have used it one time please place check in the correct column).Chocolate Currently UsePast UseNever Use Sweets Currently UsePast UseNever Use Alcohol Currently UsePast UseNever Use Cocaine Currently UsePast UseNever Use Caffeine Currently UsePast UseNever Use Marijuana Currently UsePast UseNever Use Meth Currently UsePast UseNever Use Tobacco Currently UsePast UseNever Use Adderall / Dexamphetamine Currently UsePast UseNever Use Ritalin Currently UsePast UseNever Use Wellbutrin / Bupropion Currently UsePast UseNever Use------------------------------------------------------------------------------------------------------------ Type 3: GABA: Calmness, relaxation, stress tolerance, muscle pain relief. 0 = Not experienced at all | 1 = Felt slightly or infrequently through to 10 = Unbearable or All the time. Stiff and tense muscles Stressed, burnt out Unable to relax/loosen up, get to sleep Often feel overwhelmed Craving substances for stress relief------------------------------------- GABA (L-Theanine, Theanine Serene, True Calm) Please place a check in the correct column. (Even if you have used it one time please place check in the correct column).Starch Currently UsePast UseNever Use Sweets Currently UsePast UseNever Use Alcohol Currently UsePast UseNever Use Marijuana Currently UsePast UseNever Use Tobacco Currently UsePast UseNever Use Ativan / Lorazepam Currently UsePast UseNever Use Klonopin / Clonazepam Currently UsePast UseNever Use Neurontin / Gabapentin Currently UsePast UseNever Use Valium / Diazepam Currently UsePast UseNever Use Xanax / Alprazolam Currently UsePast UseNever Use Other Benziodiazapene Currently UsePast UseNever Use------------------------------------------------------------------------------------------------------------ Type 4: Endorphins: Psychological and physical pain relief, pleasure, reward, loving feelings, numbness. Please rate on a scale of 1-10 with 10 being the most severe. Sensitive to emotional or physical pain Tear up, cry easily History of chronic pain Love and crave comfort Love and crave pleasure Reward or numbness from substances Reward or numbness from behaviors Self-harm Love or crave exercise Grief, loneliness "Love" or get a high from foods or drugs "Love" or get a high from behaviors such as purging or starving ------------------------------------- Endorphines (DLPA, D-Pheylalanine, Total Amino Solutions) Please place a check in the correct column. (Even if you have used it one time please place check in the correct column).Chocolate Currently UsePast UseNever Use Starch Currently UsePast UseNever Use Alcohol Currently UsePast UseNever Use Caffeine Currently UsePast UseNever Use Heroin or Opiates Currently UsePast UseNever Use Marijuana Currently UsePast UseNever Use Tobacco Currently UsePast UseNever Use Vicoden Currently UsePast UseNever Use Gaming Currently UsePast UseNever Use Porn Currently UsePast UseNever Use Sex Addiction Currently UsePast UseNever Use Shopping Addiction Currently UsePast UseNever Use------------------------------------------------------------------------------------------------------------Type 5: Low Blood Sugar: Back up fuel source for entire brain. Makes us feel stable, calm, grounded and balanced. Blood sugar balance. In this section, we are identifying substances that you consume that can impact on your REACTIVE HYPOGLYCEMIA (Blood-Sugar Balance) Cycle. Frequent craving for sugar Frequent craving for alcohol Frequent craving for starches Irritable Stressed Shaky if meals are delayed -------------------------------------Low Blood Sugar: L- Glutamine Please place a check in the correct column. (Even if you have used it one time please place check in the correct column).Sweets Currently UsePast UseNever Use Starch Currently UsePast UseNever Use Tobacco Currently UsePast UseNever Use I understand and agree that if I answer 'YES' to any of the questions below – I will READ the information provided AND seek guidance from an appropriate specialist practitioner or my physician PRIOR to taking any particular Amino Acid YesNo Are you PREGNANT or NURSING? YesNo Are you regularly USING MEDICATIONS or HERBS? YesNo Do any of these conditions apply to you? You have a serious LIVER Condition (e.g., cirrhosis)You have a serious KIDNEY Condition (e.g., lupus disease)You currently have or have in the past had Cancer?You have A-Fib (Atrial fibrillation)?You have an Ulcer (amino acids are slightly acidic)?You have Schizophrenia?You have a Bipolar spectrum disorder?You have another mental health illness (especially if not stabilized on medication)?None of the above Do any of these conditions / disorders apply to you? In which case you should avoid the specific amino acids indicated in your report. You have PKU (phenylketonuria) Can’t break down pheylalanineYou have an Overactive thyroidYou have an Seizure disorderYou have MelanomaYou have a carcinoid tumour (a pathological producer of serotonin)You have Glutamine-fueled cancerYou have a Thyroid disorderYou have an Autoimmune disorderYou have a Depressive disorderYou have an Hormonal disorderYou have an Lymphoproliferative disorderNone of the aboveIf any of the following apply to you, please follow the cautions in your report A tendency to react adversely to supplements generallyMigraine headachesHashimoto’s Thyroiditis (in some casesAsthma (rare)Sleep disturbanceNone of the aboveDo any of these conditions / disorders apply to you? In which case you should consult with your physician before taking the amino acids in your repor ManiaHigh Blood PressureLow Blood PressureAre taking medications that target serotonin* e.g., SSRIs, most SNRIs, MAOIs, tricyclics, anti-migraine medication like Imitrex, antimicrobials like LinezolidHigh blood / sugar – DiabeticLow blood / sugar – HypoglycemicNone of the above
