Name
*
First Name
Last Name
GABA:
Please check the boxes that apply to you:
Tally up the number of boxes you ticked above:
1
2
3
4
5
6
SEROTONIN:
Please check the boxes that apply to you:
Tally up the number of boxes you ticked above:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
CATECHOLAMINES:
Please check the boxes that apply to you:
Tally up the number of boxes you ticked above:
1
2
3
4
5
6
7
8
ENDORPHINS:
Please check the boxes that apply to you:
Tally up the number of boxes you ticked above:
1
2
3
4
5
6
PYROLUREA:
Please check the boxes that apply to you:
Tally up the number of boxes you ticked above:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
PYROLUREA (less common signs & symptoms):
Please check the boxes that apply to you:
Tally up the number of boxes you ticked above:
1
2
3
4
5
6
7
8
9
10
11
12
13