Mood and Stress - PRACTITIONER Form

Mood and Stress Questionnaire - Practitioner Form

PART 2: PRACTITIONER TO FILL OUT

Herbal Formula

Add the scores for each section in Part 1 and enter the total into the ‘score’ column below.

• Rank each section based on the score in descending order (i.e. 1 is the top score, 2 is the second highest, etc).
• Rank 1 indicates the most relevant prescription for your patient.
• If the top scores are close, check the questions relevant to the section and ascertain which is most relevant to your patient.

Section 1 - Adaptan:

Score:

Rank:

Section 2 - Adrenotone:

Score:

Rank:

Section 3 - Infla-Mood:

Score:

Rank:

Section 4 - NeuroCalm:

Score:

Rank:

Section 5 - Relaxan (females) or AndroLift (males):

Score:

Rank:

Section 6 - Resilian:

Score:

Rank:

Section 7 - NeuroCalm Sleep:

Score:

Rank:

Magnesium Formula
Choose the most appropriate magnesium formula below

Choose the most appropriate magnesium formula below

Prescription:

B vitamin support:

PRODUCT: HPA Essentials

DOSE: 1 Tablet BD

Magnesium formula:

Magnesium formula Product:

Dose:

Herbal formula (ranked 1st in patient answers):

Herbal formula I Product:

Dose:

Herbal formula (optional) (ranked 2nd in patient answers):

Herbal formula II Product:

Dose:

Additional support at Practitioner’s discretion:

Additional Support Product:

Dose:

Additional support at Practitioner’s discretion:

Additional Support Product:

Dose:

Mood and Stress Questionnaire - Practitioner Form

PART 2: PRACTITIONER TO FILL OUT

Section 1 - Adaptan:

Section 2 - Adrenotone:

Section 3 - Infla-Mood:

Section 4 - NeuroCalm:

Section 5 - Relaxan (females) or AndroLift (males):

Section 6 - Resilian:

Section 7 - NeuroCalm Sleep:

Magnesium FormulaChoose the most appropriate magnesium formula below

Prescription:

B vitamin support:

Magnesium formula:

Herbal formula (ranked 1st in patient answers):

Herbal formula (optional) (ranked 2nd in patient answers):

Additional support at Practitioner’s discretion:

Additional support at Practitioner’s discretion:

Magnesium Formula
Choose the most appropriate magnesium formula below