Tourette's Syndrome Symptom Evaluation Form
 
The following symptoms of Tourette's Syndrome 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
Has motor ties involving the head, upper or lower limbs
             
Mental coprolalia - has recurrent or persistent and unwelcome thoughts
             
Motor ties: touching
             
Stuttering
             
Deep knee bends
             
Squatting
             
Twirling when walking
             
Eye blinking
             
Vocal ties: clicks
             
Grunts
             
Yelps
             
Barks
             
Sniffs
             
Coughs
             
Words
             
Coprolalia (swearing)              
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