Neuro Q

Neuro-Q

Clinically validated question to find the science behind your patients symptoms.

Let’s get started!

Neuro-Q is meant to be easy. Simply have your patient go line by line and answer the questions to their best ability.

Once answers are submitted, the custom report will populate and an email will be sent to the email address provided in the survey with a copy of the report attached. Save the report for your records and feel free to share with your patients after their appointment.

Yours In health – the NeuroScience team

General information

* required field

Name*

Are you?

Male

Female

Unspecified

Age

Have you taken supplements in the past?

Yes

State

At the moment, what is your primary interest in taking supplements?

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How long (in minutes) has it taken you to fall asleep each night?

During the past month, how often have you had trouble sleeping because you cannot fall asleep within 30 minutes

During the past month, how often have you had trouble sleeping because you wake up in the middle of the night or early in the morning

During the past month, how often have you had trouble sleeping because you feel too hot

During the past month, how often have you had trouble sleeping because you have pain

During the past month, how often have you had trouble sleeping because of other reasons

During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

During the past month, how often has it been difficult for you to keep up enthusiasm to get things done?

During the past month, how would you rate your overall sleep quality?

In the last month, how often have you been upset because something happened to you unexpectedly?

In the last month, how often have you felt that you were unable to control the important things in your life?

In the last month, how often have you felt nervous and stressed?

In the last month, how often have you felt confident in your ability to handle personal problems?

In the last month, how often have you felt that things were going your way?

In the last month, how often have you found that you could not cope with all of the things you had to do?

In the last month, how often have you been able to control the irritations in your life?

In the last month, how often have you felt that you were on top of things?

In the last month, how often have you been angered because of things that happened that were outside of your control?

In the last month, how often have you felt that difficulties were piling up so high that you could not overcome them?

On average, how often do you have abdominal discomfort and poorly formed (loose) stool?

On average, how often does stress disrupt your ability to think or focus?

I feel fit

Physically, I am only able to do a little

I feel very active

I feel like doing all sorts of nice things

I feel tired

I think I do a lot in a day

When I am doing something, I can keep my thoughts on it

Physically, I can take doing a lot

I dread having to do things

I think I do very little in a day

I can concentrate well

I am rested

It takes a lot of effort to concentrate on things

Physically, I am in bad condition

I have a lot of plans

I tire easily

I get little done

I don't feel like doing anything

My thoughts easily wander

Physically, I feel that I am in excellent condition

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Lifestyle & nutrition (optional)

Do you follow any of the following special diets?

On average, how many servings of fresh fruit and vegetables do you eat in a day?

How many servings of fish (rich in omega-3 fatty acids) in a week? (e.g. salmon, tuna, sardines)

On average, how many servings of high fiber food do you eat in a day? (e.g. whole grains, green vegetables, seeds, beans)

On average, how many servings of protein do you eat in a day?

On average, how many servings of calcium-rich food do you eat in a day? (e.g. dairy products, beans, green vegetables)

How would you describe your activity/fitness level?

On average, how many alcoholic drinks do you consume on a weekly basis?

Please select any food allergies/sensitivities among the following.

When it comes to vitamins and supplements, how would you describe yourself?

When it comes to swallowing tablets and capsules, you are…

Once your results are submitted, your healthcare provider will be notified.