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others. When you fill out the questions and send it to us, we must ask you for certain personal information so
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process will not be shared or used in any other way.
Health Questionnaire (NTAF)
Please check the appropriate number “0-3” on all questions below. 0 as the least/never to
3 as the most/always.
Please list any natural supplements you currently take and for what conditions:
Acetylcholine Receptor Antagonist ? Antimuscarinic Agents
if yes, describe
(Atropine, Ipratopium, Scopolamine, Tiotropium)
Acetylcholine Receptor Antagonist - Ganlionic Blockers
(Mecamylamine, Hexamethonium, Nicotine (high doses), Trimethaphan)
if yes, describe
Acetylcholine Receptor Antagonist - Neuromuscular Blockers
(Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, Uccinylcholine, Tubocurarine, Vecuronium, Hemicholine)
Agonist Modulator of GABA Receptor (benzodiazepines)
(Xanax, Lexotanil, Lexotan, Librium, Klonopin, Valium, ProSon, Rohypnol, Dalmane, Ativan, Loramet, Sedoxil, Dormicum, Megadon, Serax , Restoril, Halcion)
Cholinesterase Inhibitors (irreversible)
(Echotiophate, Isofl urophate, Organophosphate Insecticides, Organophosphate-containing nerve agents)
Cholinesterase Inhibitors (reversible)
(Donepezil, Galatamine, Rivastigmine, Tacrine, THC, Erophonium, Neostigmine, Phystigimine, Pyridostigmine, Carbamate Insecticidses)
Dopamine Reuptake Inhibitors
Dopamine Receptor Agonists
(Mirapex, Sifrol, Requip)
D2 Dopamine Receptor Blockers (antipsychotics)
(Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Vesprin, Nozinan, Depixol, Navane, luanxol, Clopixol, Acuphase, Haldol, Orap, Clozaril, Zyprexa, Zydis, Seroquel, Geodon, Solian, Invega, Abilify)
GABA Antagonist Competitive binder
Monoamine Oxidase Inhibitor (MAOI)
(Marplan, Aurorix, Maneric, Moclodura, Nardil, Adlegiine, Elepryl, Azilect, Marsilid, Iprozid, Ipronid, Rivivol, Popilniazida, Zyvox, Zyvoxid)
Noradrenergic and Specific Sertonergic Antidepressants (NaSSaa)
(Remeron, Zispin, Avanza, Norset, Remergil, Axit)
Selective Serotonin Reuptake Inhibitor
(Paxil, Zoloft, Prozac, Celexa, Lexapro, Luvox, Cipramil , Emocal, Serpam, Seropram, Cipralex, Esteria, Fontex, Seromex, Seronil, Sarafem, Fluctin, Faverin, Seroxat, Aropax, Deroxat, Rexetin, Xentor, Paroxat,
Lustral, Serlain, Dapoxetine)
Selective Serotonin Reuptake Enhancers
(Stablon, Coaxil, Tatinol)
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
(Effexor, Pristiq, Meridia, Serzone, Dalcipran, Despramine, Duloxetine)
Tricylic Antidepresseants (TCAs)
(Elavil, Endep, Tryptanol, Trepiline, Asendin, Asendis, Defanyl, Demolox, Moxadil, Anafranil, Norpramin, Pertofrane, Prothiadin, Thanden, Adapin, Sinequan, Trofranil, Janamine, Gamanil, Aventyl, Pamelor,
Opipramol, Vivactil, Rhotrimine, Surmontil)
The information contained here should not be construed as a claim or representation than any product
or result constitutes a specific cure, palliative or ameliorative. Any products used from myvits should be
considered as adjunctive therapy to other accepted procedures, deemed necessary by the attending,
licensed doctor of your own choosing.
Vitamins listed in your evaluation are not intended to be used as a treatment or diagnosis of any disease
or condition. All support is intended for nutritional purposes only. For treating any medical conditions,
use appropriate drug intervention by a physician.
It is the concern of the Department of Health and Human Services that no homeopathic and /or
nutritional supplements be used to replace established, conventional medical approaches; especially in
cases of emergencies, serious or life threatening diseases or conditions. Myvits shares in this concern,
as replacing conventional treatments with such products, especially in serious cases, may deprive you
of necessary treatment and thereby cause harm which could be prevented if proper treatment was given.
Do not use any of these formulas of nutritional products as replacements for conventional medical
The information you are receiving has not been evaluated by the Food and Drug Administration. The
products mentioned on myvits.com and these results are not intended to diagnosis, treat, cure, or
The information you are receiving is solely the opinion of myvits.com.
It is not to be construed or intended as providing medical or legal advice.
The information is not intended to be a substitute for personalized medical
attention and advice.
This information is not necessarily considered
mainstream medicine. It is left to the discretion and is the sole
responsibility of the user of this information indicated on this website and
questionnaire to determine if any nutritional therapy described is appropriate