Section A – General Brain Function

Section B – General Brain Function/Stress

Section C – Sugar Balance ·
Section C1 – Blood Sugar Fluctuation

·Section C2 – Insulin Resistance

Section 1 – Serotonin

Section 1 – Serotonin (continued)

Section 2 – Dopamine

Section 3 – GABA

Section 4 - Acetylcholine

Medication History

Please circle any of the following medication you have been or are currently taking.

Agonist Modulator of GABA Receptor (benzodiazpines)

Xanax, Lexotanil, Lexotan, Librium, Klonopin, Valium, ProSon, Rohypnol, Dalmane, Ativan, Loramet, Sedoxil, Dormicum, Megadon, Serax , Restoril, Halcion

Agonist Modulator of GABA Receptors (nonbenzodiazpines)

Ambien, Sonata, Lunesta, Imovane

GABAAntagonist Competitive binder

Flumazenil

D2 Dopamine Receptors Blockers (antipsychotics)

Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Vesprin, Nozinan, Depixol, Navane, luanxol, Clopixol, Acuphase, Haldol, Orap, Clozaril, Zyprexa, Zydis, Seroquel, Geodon, Solian, Invega, Abilify

Dopamine Receptors Agonists

Mirapex, Sifrol, Requip

Acetylcholine Receptor Agonists

Bethenacol, Carbachol, Cervimeline, Pilocarpine, Suberylcholine, Nicotine

Cholinesterase Inhibitors (reversible)

Donepezil, Galatamine, Rivastigmine, Tacrine, THC, Erophonium, Neostigmine, Phystigimine, Pyridostigmine, Carbamate Insecticidses

Cholinesterase Inhibitors (irreversible)

Echotiophate, Isoflurophate, Organophosphate Insecticides, Organophosphate-containing nerve agents

Acetylcholinesterase Reactivators

Pralidoxime

Acetylcholine Receptor Antagonist – Antimuscarinic Agents

Atropine, Ipratopium, Scopolamine, Tiotropium

Acetylcholine Receptor Antagonist - Ganlionic Blockers

Mecamylamine, Hexamethonium, Nicotine (high doses), Trimethaphan

Acetylcholine Receptor Antagonist - Neuromuscular Blockers

Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, uccinylcholine, Tubocurarine, Vecuronium, Hemicholine

Selective Serotonin Reuptake Inhibitor

Paxil, Zoloft, Prozac, Celexa, Lexapro, Luvox, Cipramil , Emocal, Serpam, Seropram, Cipralex, Esteria, Fontex, Seromex, Seronil, Sarafem, Fluctin, Faverin, Seroxat, Aropax, Deroxat, Rexetin, Xentor, Paroxat, Lustral, Serlain, Dapoxetine

Selective Serotonin Reuptake Enhancers

Stablon, Coaxil, Tatinol

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Effexor, Pristiq, Meridia, Serzone, Dalcipran, Despramine, Duloxetine

Noradrenergic and Specifi energic and Specific Sertonergic c Sertonergic Antidepr Antidepressants (NaSSaa)

Remeron, Zispin, Avanza, Norset, Remergil, Axit

Tricylic Antidepresseants (TCAs)

Elavil, Endep, Tryptanol, Trepiline, Asendin, Asendis, Defanyl, Demolox, Moxadil, Anafranil, Norpramin, Pertofrane, Prothiadin, Thanden, Adapin, Sinequan, Trofranil, Janamine, Gamanil, Aventyl, Pamelor, Opipramol, Vivactil, Rhotrimine, Surmontil

Monoamine Oxidase Inhibitor (MAOI)

Marplan, Aurorix, Maneric, Moclodura, Nardil, Adlegiine, Elepryl, Azilect, Marsilid, Iprozid, Ipronid, Rivivol, Popilniazida, Zyvox, Zyvoxid

Dopamine Reuptake Inhibitors

Wellbutrin (Bupropion)