To help determine which nutrients are needed by the body to overcome OCD or GAD

Obsessive Compulsive Disorder

This Questionnaire helps you  determine if a thin myelin may be contributing to your Obsessive Compulsive disorder (OCD), Panic attacks, GAD and anxiety and if you are a candidate for the protocol of which I work..  It also helps me determine which nutrients to suggest to help your body rebuild the myelin in hopes of reverse the conditions which causes OCD.

Thin Myelin Test

Thin myelin sheathing is a common denominator of many people who suffer from:  

  • OCD
  • Bi-polarity
  • Trichotillomania
  • Bell's Palsy
  • Shingles
  • Parkinson's disease
  • MS (Multiple Sclerosis)
  • Anorexia
  • Depression
  •  Bulimia
  •  Body Dysmorphia
  • Self Injury or Self Cutting
  • Panic Attacks
  • Social Anxiety/Phobia
  • Tourette's Syndrome
  • ADD
  • Phobias
  • Other neurological disorders

Why should I complete this survey?  

Completing this survey will help you to determine your myelin sheathing’s level of health. Your answers will also help us to gather statistics to prove to the medical community that OCD and similar conditions are biologically based, which causes psychological symptoms, rather than just being purely psychological.


All information that you provide will be kept in strict confidence.

Your Name:

Your Name:


Name of person this questionnaire is about (write same if it is you):

Name of person this questionnaire is about (write same if it is you):

Name

Email

Email


Confirm Email

Confirm Email


Date of Birth of patient DD/MM/Year

Date of Birth of patient DD/MM/Year


Sex of person whose information is on this questionnaire

Sex of person whose information is on this questionnaire

Do you want to be contacted with a protocol suggestion

Do you want to be contacted with a protocol suggestion


How often do you have dreams with no nightmares?

Do you hear voices or sounds which are not really there?

Do you try to avoid large groups of people?

Does noise or commotion get on your nerves?

Do you have a hard time concentrating when things are going on?

Do you have invasive thoughts?

Do you play background noise like a TV, Fan or Air Conditioner to drown out noises to go to sleep?

Does sudden noises startle you?

Do you have rituals that you need to do to feel okay?

Do you tend to turn things off or down when someone is talking to you?

Have you had the sensation that someone has touched you or sit next to you but there isn't anyone there?

Do you ever think you see someone, something or movement out of the corner of your eye but with a second look it is no longer there.

Do you forget where you are or what direction a common place is?

Do you forget common words or names?

Do you have a hard time getting a song or thought out of your mind?

Do you feel compelled to say your prayers over and over again?

How often do you have bowel movements?

Do you get night sweats?

Do the muscles down the top of your shoulder/neck get tight?

Do you feel bloated after you eat?

Do you have flatulence (passing gas) more than 1 time a week?

Do you have poor night vision?

Do you suffer from symptoms of low blood sugar?

Do you have symptoms of high sugar, diabetes or feeling tired after a large meal?

Do you wake up at night (for any reason and any length of time)?

Do you have or have you ever had psoriasis, eczema, or skin rashes

Do you  have or have you ever had moles or skin tags?

If female, do you have or have you ever had light or missed periods?

If female, do you have or have you ever had heavy periods?

If female, have you have or have you ever had fibroids, cysts or tumors in the breast?

If female, do you have or have you ever had mood swings or PMS?

If female do you have or have you ever had cysts on either of your ovaries?

Have you ever had night sweats or hot flashes?

If male have you ever had high PSA or swollen prostate?

Do you experence mood swings and/or depression?

Do you now or have you ever had LOW blood pressure?

Do you now or have you ever had HIGH blood pressure?

Does your skin get dark where clothes or skin rubs together?

Do ever get anxiety or panic attacks?

Do you have a hard time getting to bed early?

Do you have a hard time getting out of bed in the morning?

Do you have an energy dip around 2 to 3 pm and then get a second wind after supper?

Other Remarks:

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