First Name

Middle Name

Last Name

Date of Birth

SSN #

Age

Sex FemaleMale

Marital Status MarriedSingleWidowedDivorced

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone Number

Cell Phone Number

Email

Employer

Work Phone Number

Emergency Contact

Emergency Contact Number

Relation to patient

Height

Weight

Major Complaint

Referred by

First Name

Middle Name

Last Name

Date of Birth

SSN #

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone Number

Cell Phone Number

Drivers License # and State

Employer

Work Phone Number

Parent/Guardian Signature

Present Height

Present Weight

Minimum Adult Weight

Maximum Adult Weight

Ideal Weight (if applicable)

Has anyone in your family had any of the following? If positive, indicate mother/father/brother/sister/child/maternal/paternal

Obesity

Diabetes

Stroke

Heart Disease

Arthritis

Cancer

Have you had any of the following?
PneumoniaTuberculosisRheumatic FeverHeart DiseaseCoronary DiseaseHigh Blood PressureKidney DiseaseUlcer DiseaseAnemiaKidney StonesBowel DiseaseGoutAsthmaArthritisGallstonesSeizureConvulsions

Diabetes
BorderlineChemicalJuvenile OnsetAdult Onset

If so, when?

Surgeries

Hospitalizations

Serious Illness not needing hospitalizations (include reasons, diagnosis, and date)

Are you presently undergoing treatment for emotional or psychological problems?

Have you ever been hospitalized for psychological problems?

Please select Yes or No

Frequent or constant headache
YesNo

Fainting spells, convulsions
YesNo

Dizziness
YesNo

Loss of Hearing
YesNo

Change of Vision
YesNo

Dental Trouble
YesNo

Bleeding Gums
YesNo

Lumps on the Neck
YesNo

Please select Yes or No

Chest Pain
YesNo

Shortness of Breath
YesNo

Chronic Cough
YesNo

Sputum
YesNo

Cramps in Legs
YesNo

Varicose Veins
YesNo

Phlebitis (inflamed leg veins)
YesNo

Swelling of Legs/Ankles
YesNo

Rapid/Irregular Heartbeat
YesNo

Comments

Please select Yes or No

Indigestion or Heartburn
YesNo

Nausea
YesNo

Vomiting Blood
YesNo

Pain/Abdominal Cramps
YesNo

Diarrhea
YesNo

Black Diarrhea
YesNo

Bloody Diarrhea
YesNo

Constipation
YesNo

Average number of bowel movements per day

Average number of bowel movements per week

Daytime sleepiness
YesNo

Insomnia
YesNo

Normal sleep (average 6-8 hours)
YesNo

Always hot
YesNo

Always cold
YesNo

Excessive Hair
YesNo

Loss of Hair
YesNo

Skin Texture (problems)
YesNo

Have you ever had a reaction to any of the following:

Milk or dairy products
YesNo

Eggs
YesNo

Drugs or Medications
YesNo

Comments

Do you consider yourself an active person?
YesNo

Do you walk a mile or more per day?
YesNo

Do you exercise on a regular basis?
YesNo

If so, what type?

How often?

Comments

Pain
YesNo

Incontinence
YesNo

Frequent Night Time Urination
YesNo

Impotence
YesNo

Menstrual discharge
YesNo

Pain during intercourse
YesNo

Normal cycle
YesNo

Vaginal dryness
YesNo

Unusual complications
YesNo

Lumps on breast
YesNo

Discharge from nipple
YesNo

Excessive discomfort
YesNo

Last Menstrual Date

Last Gynecological Exam

Full Term Live
YesNo

Caesareans
YesNo

Miscarriage/Abortion
YesNo

Complications
YesNo

Stillbirth
YesNo

Comments

Joint Pain
YesNo

Back Pain
YesNo

Swelling YesNo

Comments

Do you ever use the following?

Tobacco YesNo

Coffee YesNo

Alcohol YesNo

Tea YesNo

Comments

Do you have diabetes? YesNo

If so, for how long?

Do you check your blood sugar? YesNo

How often?

Do you take insulin? YesNo

Do you take medications?
YesNo

Do you have numbness, tingling, or burning in feet?
YesNo

Do you ever have hypoglycemia or low blood sugars (less than 70)?
YesNo

How often? ___/week?

How do you treat?

Do you have any allergies?

Please list current medications and dosage

(Score as pertains to most days)

Depression (1 is Never, 10 is Suicidal Thoughts)
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Anxiety (1 is Never, 10 is Constant)
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Joy (1 is Never, 10 is Always)
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Motivation/Energy (1 is None, 10 is High)
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Libido (sex drive) (1 is None, 10 is High)
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Sleep (1 is Never sleep well, 10 is Perfect sleep)
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(for patients interested in nutrition therapy)

CASH Scale: Compulsions or Cravings/Appetite/Satiety/Hunger

Each feeling represents a different part of the brain and different neurotransmitters.

Compulsions/Cravings – A feeling or urge to eat when not hungry, often associated with other emotions such as “stress eating”. You want food. There is no food in sight. You get an urge to eat which cannot be repressed. (1 is Never Occurs, 10 is Constant)
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Appetite – A feeling of hunger stimulated by sight, sounds, smells, or social cues. You recently ate and feel full. You walk into a room and there is food everywhere. It looks and smells good, and everyone is having fun. You: (1 is Never Eat, 10 is Always Eat)
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Satiety – A feeling of fullness acquired during eating. When you eat you usually: (1 is One Plate Always, 10 is Second or third servings)
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Hunger – That feeling of a true pain or ache in your stomach when really empty. This is a true pain or discomfort. (1 is Never Hungry, 10 is Constantly Hungry)
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Has there ever been a period of time when you were not your usual self and…

…you felt so good or so hyper that other people thought you were not your normal self or you were so hyper you got in trouble?
YesNo

…you were so irritable that you shouted at people or started fights or arguments?
YesNo

…you felt much more self-confident than usual?
YesNo

…you got much less sleep than usual and found that you didn’t really miss it?
YesNo

…you were more talkative or spoke much faster than usual?
YesNo

…your thoughts raced through your head and you couldn’t slow your mind down?
YesNo

…you were so easily distracted by things around you that you had trouble concentrating or staying on track?
YesNo

…you had much more energy than usual?
YesNo

…you were much more active or did many more things than usual?
YesNo

…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
YesNo

…you were much more interested in sex than usual?
YesNo

…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
YesNo

…your spending money got you or your family in trouble?
YesNo

If you checked YES to more than one fo the above, have several of these every happened during the same period of time?
YesNo

How much of a problem did any of these cause you- like being able to work; having family, money, or legal trouble; getting into arguments or fights? (1 is No Problem, 5 is Serious Problem)
12345

Have any of your blood relatives (children, siblings, parents, grandparents, aunts, uncles) had a manic-depressive illness or bipolar disorder?
YesNo

Has a health professional ever told you that you have a manic-depressive illness or bipolar disorder?
YesNo

Signature of Patient

Please rate your symptoms below

Heartburn (1 is None, 10 is Severe/Constant)
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Back Pain (1 is None, 10 is Severe/Constant)
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Joint Pain (Knee/hip/feet) (1 is None, 10 is Severe/Constant)
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Difficulty Breathing (1 is None, 10 is Severe/Constant)
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Depression (1 is None, 10 is Severe/Thoughts of suicide)
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Tiredness/Fatigue (1 is None, 10 is Severe/Constant)
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Headache (1 is None/Rare, 10 is Severe/Daily)
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Insomnia/Difficulty Sleeping (1 is Perfect Sleep, 10 is Never Sleep Well)
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Happiness (1 is Never Happy, 10 is Always Happy)
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Signature of Patient

***Patient privacy disclaimer*** The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of Stanford Owen, M.D. If the content of this form reaches you and you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message. If you have received this transmission in error, please notify us immediately at (228) 864-9669 or drowenmd@drdiet.com.

Patient Instructions:

Please rate yourself on each of the symptoms listed below using the following scale. For completeness, some questions will be asked more than once.

If possible, to give us the most complete picture, have another person who knows you well (such as a spouse, partner, or parent) rate you too. Their answer can go below (under OTHER) in the form of a number.

First Name

Last Name

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Phone Number

Email

1. Fail to pay close attention to details or make careless mistakes 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

2. Trouble sustaining attention 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

3. Do not seem to listen when spoken to directly 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

4. Poor follow through 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

5. Disorganized 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

6. Avoid tasks that require sustained effort 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

7. Lose things 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

8. Easily distracted 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

9. Forgetful checkbox q-9 “0 – Never” “1 – Rarely” “2 – Occasionally” “3- Frequently” “4 – Very Frequently” “N/A – Not Applicable”]

ADHD INATTENTIVE SYMPTOMS: Questions 1 – 9

Highly probable —– 6 questions with 3 or 4
Probable —– 4 questions with 3 or 4
May be possible —– 3 questions with 3 or 4

10. Fidgety 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

11. Trouble sitting still 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

12. Restless 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

13. Unable to play or engage in leisure activities quietly 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

14. “On the go” or acting as if “driven by a motor” 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

15. Talks excessively 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

16. Blurt out answers before questions have been completed ( e.g., complete people’s sentences; cannot wait for turn in conversation) 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

17. Difficulty waiting (e.g., waiting in line) 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

18. Interrupts others 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

HYPERACTIVITY/IMPULSIVITY SYMPTOMS: Questions 10 – 18

Highly probable —– 6 questions with 3 or 4

Probable —– 4 questions with 3 or 4

May be possible —– 3 questions with 3 or 4

19. Make decisions or behave impulsively (saying or doing things without thinking) 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

20. Difficulty delaying what I want 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

21. Accident prone, traffic violations or near accidents 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

IMPULSIVITY SYMPTOMS: Questions 16 – 21

Highly probable —– 6 questions with 3 or 4

Probable —– 4 questions with 3 or 4

May be possible —– 3 questions with 3 or 4

22. Overwhelmed by the tasks of everyday life 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

23. Difficulty expressing feelings 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

24. Difficulty expressing empathy for others 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

25. Late or in a hurry 0 – Never1 – Rarely2 – Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

PREFRONTAL CORTEX (PFC) SYMPTOMS: Questions 1 – 25

Highly probable —– 6 questions with 3 or 4

Probable —– 4 questions with 3 or 4

May be possible —– 3 questions with 3 or 4

26. Get stuck on negative thoughts or behaviors 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

27. Recurrent bothersome thoughts or images I try to ignore 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

28. Compulsive behaviors (such as excessive hand washing, checking locks, counting, or spelling) to avoid feeling anxious 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

29. Worry 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

30. Upset when things do not go my way 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

31. Upset when things are out of place 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

32. Oppositional or argumentative 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

33. Dislike change 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

34. Hold grudges 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

35. Hold onto own opinion and do not seem to listen to others 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

36. Tend to say no without first thinking about the question 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

37. Need to be perfect 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

OVERFOCUSED SYMPTOMS: Questions 26 – 37

Highly probable —– 8 questions with 3 or 4
Probable —– 6 questions with 3 or 4
May be possible —– 4 questions with 3 or 4

38. Depressed or sad mood 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

39. Crying spells 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

40. Negativity 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

41. Decreased interest in people or pleasurable activities 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

42. Feel worthless helpless, hopeless, or guilty 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

43. Fatigue, feeling tired, or lack of energy 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

44. Decreased concentration or memory 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

45. Recurrent thoughts of death or suicide 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

46. Insomnia or trouble sleeping 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

47. Excessive sleeping 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

48. Irritable or easily agitated 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

49. Recent decrease in appetite or weight 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

50. Recent increase in appetite or weight 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

LIMBIC SYMPTOMS/DEPRESSION: Questions 38 – 50

Highly probable —– 7 questions with 3 or 4
Probable —– 5 questions with 3 or 4
May be possible —– 4 questions with 3 or 4

51. Significant mood swings or cycles 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

52. Periods of an elevated, high, or irritable mood 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

53. Periods of very high self-esteem or grandiose thinking 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

54. Periods of decreased need for sleep without feeling tired 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

55. Periods of being more talkative than usual or feeling pressure to keep talking 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

56. Racing thoughts or frequently jumping from one subject to another 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

57. Easily distracted by irrelevant things 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

58. Feel a marked increase in physical activity level 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

59. Excessive involvement in pleasurable activities that have a high risk for negative consequences (e.g., spending money, sexual indiscretions, or gambling) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

60. Anxious, tense, or nervous 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

61. Panic attacks, which are periods of intense, unexpected fear or emotional discomfort 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

62. Fear of dying 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

63. Fear of going crazy or doing something out-of-control 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

64. Predict the worst 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

65. Avoid conflict 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

66. Excessive motivation or can’t stop working 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

67. Freeze in anxious or upsetting situations 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

68. Shy or timid 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

69. Easily embarrassed 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

70. Sensitive to criticism 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

71. Bites fingernails or picks at skin 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

72. Lack of confidence in abilities 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

73. Need a lot of reassurance 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

BASAL GANGLIA/GENERALIZED ANXIETY DISORDER: Questions 60 – 73

Highly probable —– 6 questions with 3 or 4
Probable —– 4 questions with 3 or 4
May be possible —– 3 questions with 3 or 4

74. Avoid everyday places for 1) fear of having a panic attack or 2) needing to go with other people in order to feel comfortable 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

75. Recurrent and upsetting thoughts of a past traumatic event (molestation, accident, fire, etc..) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

76. Recurrent distressing dreams of a past upsetting event 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

77. Reliving a past upsetting event 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

78. Panic or fear of events that resemble an upsetting past event 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

79. Spend effort avoiding thoughts or feelings associated with past trauma 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

80. Avoid activities/situations which remind me of past upsetting events 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

81. Unable to recall an important aspect of a past upsetting event 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

82. Avoid activities/situations which remind me of a past upsetting event 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

83. Feel numb or restricted in my feelings 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

84. Feel that my future is shortened 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

85. Quick to startle 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

86. Watch for bad things to happen 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

87. Have a physical response to events that remind me of a past upsetting event (e.g., sweating, increased pulse, etc… when getting in a car if you have been in a car accident) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

88. Excessive fear of being judged by others, which causes me to avoid or get anxious in situations 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

89. Persistent, excessive phobia (heights, closed spaces, specific animals, etc…) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

90. Involuntary physical movements and/or motor tics (such as eye blinking, shoulder shrugging, head jerking, or picking) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

91. Involuntary vocal sounds or verbal tics (such as coughing, puffing, blowing, whistling, or swearing) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

92. Stutter 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

93. Refuse to maintain body weight above a level that most people consider healthy 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

94. Intense fear of gaining weight or becoming overweight even though I am underweight 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

95. Feel overweight, even though others say I am underweight 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

96. Have recurrent episodes of binge eating large amounts of food 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

97. Feel a lack of control over eating behavior 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

98. Purge food, such as self-induced vomiting or using laxatives or diuretics; partaking in strict dieting, or partaking in strenuous exercise 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

99. Overly concerned with my body shape and/or weight 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

100. Unpredictable moods 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

101. Irritability, short fuse, or easily angered 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

102. Misinterpret comments as negative when they are not 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

103. Experience illusions, such as hearing sounds that are not there (e.g., muffled voices or shots being fired); visual distortions (e.g., seeing shadows or things get bigger or smaller than they really are); or smelling odors that are not present (e.g., burned rubber) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

104. Periods of deja vu (the feeling of being somewhere you have never been) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

105. Dark, disturbing, or troubling thoughts 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

TEMPORAL LOBE SYMPTOMS (TLS) PURE: Questions 100 – 105

Highly probable —– 4 questions with 3 or 4
Probable —– 3 questions with 3 or 4
May be possible —– 2 questions with 3 or 4

106. Trouble reading the body language or facial expression of others 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

107. Trouble learning new information 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

108. Memory problems 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

109. Trouble remembering recent events 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

110. Difficulty memorizing things for school or work 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

TEMPORAL LOBE SYMPTOMS (TLS) MEMORY/LEARNING: Questions 106 – 110

Highly probable —– 4 questions with 3 or 4
Probable —– 3 questions with 3 or 4
May be possible —– 2 questions with 3 or 4

111. Delusional or bizarre thoughts (thoughts I know others would think are false) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

112. Auditory or visual hallucinations 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

113. Periods of time where my thoughts or speech were disjointed or didn’t make sense to others 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

114. Impaired ability to function at home or at work 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

115. Lack personal hygiene 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

116. Exhibit inappropriate mood for a given situation (e.g., laughing at sad events) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

117. Frequent feelings that someone or something is out to hurt or discredit me 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

118. Am a poor reader 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

119. Make mistakes when reading, such as skipping words or lines 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

120. Have problems remembering what I read even though I have just read all the words 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

121. Reverse or switch letters when I read (such as b/d, p/q) 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

122. Light sensitive and bothered by glare, sunlight, headlights, or streetlights 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

123. Become tired or experience headaches, mood changes, restlessness, or have an inability to stay focused with bright or fluorescent lights 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

124. Have trouble reading words that are on white, glossy paper 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

125. When reading, words or letters shift, shake, blur, move, run together, disappear, or become difficult to perceive 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

126. Tense, tired, sleepy, or even get headaches when reading 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

127. Problems judging distance and have difficulty with such things as escalators, stairs, ball sports, or driving 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

128. Poor handwriting or prefer to print rather than to write in cursive 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

129. Trouble getting thoughts from brain to my paper 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

130. Tend to keep notebook/paperwork/room messy or disorganized 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

131. Frequently late or in a hurry 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

132. Clumsy 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

133. More sensitive to lights, sounds or smells than others 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

134. Sensitive to touch or tags in clothing 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

135. Few or no friends 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

136. Feel uncomfortable around people whom I do not know well 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

137. Teased by others 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

138. Friends do not call and ask me to do things with them 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

139. Trouble with communication by at least one of the following (please select all that apply) A) Have delayed or total lack of spoken languageB) Have marked impairment in ability to initiate or sustain a conversation with othersC) Have repetitive use of language or odd language

140. Trouble with social interaction by at least two of the following (please select all that apply) A) Have marked impairment in the use of nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interactionB) Fail to develop peer relationshipsC) Lack of spontaneity in seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)D) Lack of social or emotional reciprocity

141. Exhibit repetitive patterns of behavior, interests, and activities by at least one of the following (please select all that apply) A) Have preoccupation with something that is abnormal either in intensity or focusB) Have rigid adherence to specific, nonfunctional routines or ritualsC) Have repetitive motor mannerisms (e.g., hand or finger flapping or twisting or complex whole-body movements)D) Have persistent preoccupation with parts of objects

142. Trouble getting or staying asleep 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

143. Restless sleep 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

144. Worry I won’t be able to fall asleep 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

145. Early morning awakenings with trouble getting back to sleep 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

146. Wake up tired and unrefreshed 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

147. Nightmares 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

148. Loud snoring 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

149. Other say I stop breathing during sleep 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

150. Get more than 7 hours of sleep at night 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

151. Crave sweets during the day 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

152. Irritable or easily upset if meals are missed 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

153. Depend on caffeine to get started or keep me going 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

154. Get lightheaded or shaky if meals are missed 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable

155. Eating relieves fatigue 0 – Never1 – Rarely2- Occasionally3- Frequently4 – Very FrequentlyN/A – Not Applicable