Neurotransmitter and Nutrition

Child Neurotransmitter & Nutrition Questionnaire (CNNQ) Patient Form

For Current Patients Undergoing Functional Medicine Treatment

Assessment Form

Complete the following form to the best of your ability and submit it to our office. We will use these forms to help in your overall healthcare assessment for better diagnosis and treatment of your issues.

Child Neurotransmitter & Nutrition Questionnaire (CNNQ)


6035 Shallowford Rd Suite 101
Chattanooga, TN 37421
OFFICE 423-499-0003 | FAX 423-485-7992


Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY

GENERAL

Please complete the following questions:

Select the appropriate answer in the range between 0 (least or never) and 3 (most or always).
Please circle the appropriate number 0-3 on all questions below. 0 as the least/never to 3 as the most/always.
SECTION: A (K52)
Does your child eat pasta breads and breaded foods?
Does your child have symptoms (fatigue, hyperactivity, etc.) after eating wheat foods?
Does your child eat dairy products?
Does your child have symptoms (fatigue, hyperactivity, etc.) after eating dairy products??
SECTION: B (K53)
Does your child eat fried fish?
Does your child eat roasted nuts or seeds?
Is your child missing essential fatty acid rich foods in his/her diet? (For example: avocadoes, flax seed, olives)?
(mark "0" if present, "3" if missing).
Does your child eat fried foods?
SECTION: C (K34)
Is your child's mental speed slow?
Does your child have difficulty with learning or memory?
Does your child have difficulty with balance and coordination?
SECTION: D (K16)
Does your child have stress?
Does your child not have enough sleep and rest?
Does your child not have regular exercise?
Does your child feel overly worried and scared?
SECTION: E (K16, K51)
Does your child have temper tantrums?
Does your child exhibit wild behavior?
Does your child yell or scream for an unnecessary reasons?
Does your child have an inability to nap or sleep when physically exhausted?
(mark 3 if unable)
Is your child overly talkative?
Does your child fidget and squirm when seated?
Does your child run and climb excessively when it is inappropriate?
Does your child have difficulty playing quietly or engaging in leisure activities?

SECTION: F (K51)
Does your child get excited easily?
Does your child have anxiousness and panic for minor reasons?
Does your child feel overwhelmed for minor reasons?
Does your child find it difficult to relax when he/she is awake?
Does your child have disorganized attention?
SECTION: G (K50)
Does your child seem depressed?
Does your child have mood changes with overcast weather?
Does your child have symptoms of inner rage?
Does your child seem uninterested in games or hobbies?
Does your child have difficulty falling into deep sleep?
Does your child seem uninterested in friendships?
Does your child have symptoms of unprovoked anger?
Does your child seem uninterested in eating?
CSECTION: H (K49)
Does your child have difficulty handling stress?
Does your child have anger and aggression while being challenged?
Does your child feel tired even after long sleeps?
Does your child tend to isolate from others?
Does your child get distracted easily?
Does your child have constant need and desire for candy and sugar?
Does your child have disorganized attention?
SECTION: I (K48)
Does your child have difficulty with visual memory?
Does your child have difficulty remembering locations?
Does your child have fatigue or low endurance for learning activities?
Does your child have difficulty with attention or low attention span or endurance?
Does your child have slow or difficult speech?
Does your child have uncoordinated or slow movement?

Symptom groups listed in this questionnaire are not intended to be used as a diagnosis if any disease condition.

APPOINTMENTS

If you are interested in scheduling a consultation to see if you are a Non-Surgical candidate or are looking to get off your medications, we are here to serve you! Simply complete the quick form on the left to send a message to our team. Our friendly office staff will take your request in the order in which it is received and we will get in touch with you either by email or phone.

EMAIL FOR AN APPOINTMENT
CALL FOR AN APPOINTMENT

If you have been seriously injured and need immediate help, call 911. If you were recently injured but need our services as soon as we can get you in, call our office for an appointment:

CALL FOR AN APPOINTMENT - (423) 499-0003.

(423) 499-0003

6035 Shallowford Rd,
Chattanooga, TN 37421

Hours of Operation:

MON: 8:30am-12:30pm  &  2:00pm-6:00pm
WED: 8:30am-12:30pm  &  2:00pm-6:00pm
THUR: 9:00am-12:30pm &  2:00pm-6:00pm
FRI: 8:30am-12:30pm  &  2:00pm-6:00pm

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