Frequency Scale
Never = 0, Rarely = 1, Sometimes = 2, Regularly = 3
Do you…
1. Have brain fog? _____
2. Need caffeine to start your day or stay awake? _____
3. “Play small” because you’re easily stressed? _____
4. Shut down in the face of stress? _____
5. Get overwhelmed or angry when stressed? _____
6. Want to run when you feel anxiety, worry, or panic? _____
7. Experience afternoon energy slumps? _____
8. Have difficulty maintaining boundaries for yourself? _____
9. Struggle to relax fully? _____
10. Have chronic inflammation? _____
11. Have to work at maintaining positivity? _____
12. Take longer to recharge than you used to? _____
13. Deal with depression? _____
14. Feel more introverted than you used to be? _____
15. Have digestive issues such as bloating, acid reflux, constipation or diarrhea?_____
16. Tend to hold onto extra weight or fluid? _____
17. Get easily startled or feel you must be hypervigilant? _____
18. Have old feelings of shame, guilt, or self-blame? _____
19. Avoid triggers that are emotionally tied to events in your life? _____
20. Have a distorted view of yourself or the world? _____
21. Partake in risky or impulsive behaviors? _____
22. Have racing thoughts? _____
23. Have event flashbacks from painful memories? _____
24. Have inconsistent blood pressure, heart rate, or blood sugar? _____
25. Feel hopeless about your life or condition? _____
26. Feel numb or dissociated from your life? _____
27. Feel like your hormones are all over the place?_____
Yes = 6, No = 0
Are you…
1. Sensitive to some foods or supplements? _____
2. Sensitive to some environments (sounds, lights, smells)? _____
3. Unable to handle even the smallest stressor? _____
4. Either dealing with or have dealt with past trauma? _____
5. Rating your emotional resiliency as a 6 or less on a scale of 1-10?____
TOTAL _____ /111
Check Your Results:
0-12 Points
No obvious nervous system dysregulation
The common signs of nervous system dysregulation, such as chronic fight or flight responses, are not apparent to you at the moment. However, nervous system dysregulation can take years to manifest noticeable symptoms so if you’re still concerned, come in for an actual Nervous System scan so we can assess further.
13-24 Points
Moderate nervous system dysregulation
It is likely that your nervous system dysregulation is preventing you from achieving the level of wellbeing that you want. Working with a neurologically-focused chiropractor can get the nervous system back online and moving into a healthier state.
25+ Points
Significant nervous system dysregulation
It is evident that you are experiencing symptoms related to nervous system dysregulation. Working with a neurologically-focused chiropractor can get the nervous system back online and moving into a healthier state. Please be aware that at this more significant level of dysregulation, you probably feel overwhelmed just thinking about starting something new. This is normal. But once you start feeling better, you will be so happy that you took that brave step and started care.
Call the office today and request a New Patient Neurological Exam with Dr. Huff - (757) 283-6929