Schizophrenia Symptom Evaluation Form
 
The following symptoms of Schizophrenia are listed as being typical. This information is being collected to determine the effectiveness of the product provided to you.
   
Please evaluate each symptom using the following scale:
0= Not at all    1= Just a little    2= Somewhat    3= Very much

Name :  
Date :  
Symptoms Sun Mon Tues Wed Thu Fri Sat
Hallucinations or delusions
             
Extremely disorganized thoughts
             
Inappropriate emotional responses
             
Abandonment of personal hygiene
             
Social withdrawal
             
Intense depression
             
Inability to concentrate
             
Avoiding activities and hobbies
             
Thoughts of death or suicide
             
Extreme religiousness or occupation with the occult
             
Drug or alcohol abuse
             
Forgetfulness
             
Unusual sensitivity to stimuli
             
Staring
             
Rigid stubbornness
             
Hyperactivity or inactivity              
Supplement dosage, sleep, and medication  
Empower daily dosage (# of capsules)              
Hours of sleep              
Drug 1 daily dosage
Name:
              
Drug 2 daily dosage
Name:		              
Drug 3: daily dosage
Name:		              
Drug 4: daily dosage
Name:		              
Drug 5: daily dosage
Name:		              

Comments  
 
 
 
 
   
*Please send completed forms to Truehope Nutritional Support Ltd.
Ph: 1-888-TRUEHOPE (1-888-878-3467)
Fax: 1-888-752-7212
Email: sef@truehope.com
Mail: P.O. Box 888, Raymond, Alberta, Canada, T0K 2S0

Copyright © 2002 Truehope Nutritional Support Ltd.
Revised October 11, 2002