WELCOME TO INFINITY WELLNESS CENTER

5000 Davis Lane Ste. 106, Austin, TX 78749 ❖ 512.328.0505

Dr. Tenesha Wards ❖ Dr. Amanda Massey ❖ Dr. Danny VanNoy

PERMISSION AND AUTHORIZATION FORM

I specifically authorize the natural health practitioner at Infinity Wellness Center to perform a neurological spinal exam and a Nutrition Response Testing health analysis and to develop a natural, complementary health improvement program for me which may include spinal adjustments, acupuncture, dietary guidelines, and nutritional supplements in order to assist me in improving my health and not for the treatment or 'cure' of any diseases.

I understand the Nutritional Response Testing is a safe, non-invasive, natural method of analyzing the body's physical and nutritional needs, and that deficiencies or imbalances in these areas could cause or contribute to various health problems.

I understand that the practitioner is not using a method for 'diagnosing' or 'treating' any disease and that no promise or guarantee has been made regarding the result of Nutritional Response Testing or any natural health, nutritional, or dietary programs recommended.

I understand that there are risks associated with chiropractic manipulations and myofascial release which may include fractures, strokes, bruising, muscular soreness, and ligamentous sprain. The ML 830 cold laser system is a Class Ilib laser that is contraindicated in areas of the body with aberrant sensation and analgesia. Class IIIb laser treatments are meant for optimizing the healing process of soft tissue injuries and are not to be used for any other condition.

Cancellation Policy: No fee is charged if24 hour notice is given for a cancellation. We understand emergencies happen and give one grace for a missed appointment without 24 hour notice. There will be a $50 charge for a second missed appointment and a credit card will be needed on file to book a follow up appointment thereafter.

I also understand that Infinity Wellness Center does NOT bill insurance companies directly nor do they accept Medicare. Tnfinity Wellness Center does provide a Super Bill with diagnostic codes to submit for reimbursement.

111is permission form applies to subsequent visits and consultations. I understand that entering my name on the signature line constitutes a legal signature confirming that I acknowledge and agree to the terms above.

Date: __________ _

Print Name: ______________ _

Signature: _______________ _

g

(Sinature of parent or guardian required for minors.)

HIP AA PRIVACY DISCLOSURE CONSENT

Privacy of your personal information is an important part of our office providing you with quality care. We understand the importance of protecting your personal infonnation. We are committed to collecting, using and disclosing your personal information responsibly.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your

information.

Uses and Disclosures

1. Your doctor or a staff member may have to disclose your health information up to and including all ofyour clinical records to another health care provider if it is necessary to refer you to them for treatmentof your health condition.

2. 1t may be necessary for the doctor and members of the staff to use your health information, examination,and treatment records and your billing records for quality control purposes or for other administratjvepurposes to efficiently and effectively run our practice.

3. Your doctor and members of the practice staff may need to use your information (ex. name, address,email, phone number, and your clinical records) to contact you to provide appointment reminders,information about treatment alternatives, or other health related information that may be of interest toyou. Appointment reminders will be sent by email to the email address you provided to us or by callingthe phone nwnber provided and leaving a message on yourvoicemail if there is no answer.

4. As our patient, you possess the right to refuse to give us the authority to contact you regarding the

above-mentioned circumstances.

Your Right to Limit Uses or Disclosures

l. You have the right to request that this office restricts how your personal information is used and/or disclosed.

2. Jf there are health care providers, hospitals, or other individuals or organ izatfons to whom you do notwant us to disclose your health information, please let us know, in writing, what individuals ororganizations to whom you do not want us to disclose your health care information.

3. We are not required to agree to your restrictions_ However, ifwe agree with your restrictions, therestrictions would have to be in writing and the restrictions will be binding on this office.

Your Right to Revoke Your Authorization

1. You have the right to revoke your consent at any time as long as we have a written statement. Thisrevocation will not apply to any action already taken by the office before receiving the formal writtennotice.

I have read and understand the above notice. I understand that entering my name on the signature line

constitutes a legal signature confirming that I acknowledge and agree to the terms above.

Name of patient/guardian Signature of patient/guardian

Date

NEW CLIENT EVALUATION

INFINITY WELLNESS CENTER

Today's Date: ______ _ How did you hear about us? ___________ _

Name: ------------ M □ F □ Birthdatc: ___ / -�/ __ Age: __ _

Mailing Address: ___________________________ _

City: ________ State: ___ Zip: ______ Occupation: _______ _

Marital Status: S □ M □ D □ W □ Weight: __ Height: __ No. of Children: ___ _

Primary Phone: _________ Secondary Phone: _________ _

Email: _____________________ _ Blood Type: ____ _

Complaints: Please tell us the main reason why you are here. _____________ _

Secondary Complaints: Please let us know any other health concerns. __________ _

Previous Treatment for these Complaints: __________________ _

Major Illnesses: ___________________________ _

Surgeries: _____________________________ _

Injuries: ______________________________ _

NEW CLIENT EVALUATION

INFINITY WELLNESS CENTER

WOMEN ONLY

Are you pregnant? Yes / No Are you nursing? Yes / No

Date of onset of last menstrual cycle: ________________ _

Any gynecologic surgeries (ie. hysterectomy, endometriosis, ovarian cysts)? _________ _

Menstrual Cycle Do you have regular monthly periods? ________________ _

Select any of the following symptoms you experience associated with your period:

Cramping Bloating Moody Cravings Heavy Bleeding Back Pain Headaches Clots

Sleep - please select: Trouble Falling Asleep Can't Stay Asleep Bad Dreams Night Sweats

Any other sleep problems? ___________________________ _

Pets: Any pets? Y / N If so, what kind and how many? ________________ _

Exercise: What kind of exercise do you do? _____________________ _

How often? ------------

Duration: -------------

Allergies List (Including Food) ______________________ _

Food Cravings: Please mark an answer for each of the questions below about food cravings, regardless of whether or not you let yourself eat these foods.

If you could have any breakfast that you wanted, which would you choose?

□ Poached eggs with hollandaise sauce

□ Bacon and eggs

□ Granola and yogurt

□ Toast and oatmeal and coffee or tea

If you could have any lunch you wanted, which would you choose?

□ Barbecued ribs or teriyaki and chips

□ Hamburger and French fries

□ A cheese sandwich and/or a milkshake

□ A sandwich, pretzels, and a soda or coffee

If you could have any dinner you wanted, which would you choose?

□ Thaifood

□ A nice steak

□ Pizza

□ Pasta with sauce

Metabolic Assessment FormTM

Name: _______________________ _ Age: ___ Sex:__ Date: __________ _

PART I Please list your 5 major health concerns in order of importance:

!. ______________________ 4. _____________________ _

2. --------------------------- 5. --------------------------

3. --------------------

PART II Please rate the following on a scale from 0-3, with 0 as the least/never to 3 as the most/always in the text box to the right of each line.

Category l Feeling that bowels do not empty completely Lower abdominal pain relieved by µassing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or '·fuzzy" debris on tongue Pass large amount of foul-smelling gas More than 3 bowel movements daily use bxatives li·equently

Category J.l Increasing frequency of food reactions Unpredictable food reaction� Aches, pains, and swelling throughout the body Unpredictable abdominal swelling frequent bloating and distention after eating

C:itcgory mIntolerance to smells fntolerunce to jewelry intolerance to shampoo, lotion, detergents; etc Multiple smell and chemical sensitivities Constant skin outbreaks

Category!\/ Excessive belching, burping, or bloating Gas immediarely following a meal Offensive breath Difficult bowel movcrncms Sense of fullness during and after meals Difficulty digesting proteins and meats;

undigested food found in stools

Category V Stomach pain, burning, or aching 1-4 hours after eating Use of antacids Feel hungry an hour or two afier eating Hea1iburn when lying down or bending forward Temporary relief by using antacids. food, milk, or

carbonated beverages Digestive problems subside with rest and rel::ixalion Heaitburn due to spicy foods, chocolate, citrus,

peppers, alcohol, and caffeine

Category vr Difficulty digesting roughage and fiber Indigestion and fullness last 2-4 hours a11er eating Pain, tenderness, soreness on left side under rib cage Excessive passage of gas Nausea and/or vomiting Stool undigested, foul smelling, mucus like,

greasy, or poorly for111ed f'rcqucnt loss of appetite

Category VIJ

Abdominal distention aner consumption of fiber, starches, and sugar

Abdominal distention after certain probiotic or natural supplements

Decreased g,astrointestinal motility. constipation Increased gastrointestinal motility, diarrhea Alternating constipation and diarrhea Suspicion ofnutTitional malabsorption Frequent use of antacid medication Have you been diagnosed with Celiac Disease,

Irritable Bowel Syndrome, Diverticulosis/ Dive1ticulitis, or Leaky Gut Syndrome?

CatcgoryVffi Greasy or high-fat foods cause distress Lower bowel gas and/or bloati11g several hours

after eating Bitter metallic taste in mouth, especially in the morning 8urpy, fishy taste after consuming fish oils Unexplained itchy skin Yellowish cast to eyes Stool color alternates from clay colored to

normal brown Reddened skin, especially palms Dry or flaky skin and/or hair History of gallbladder attacks or stones Have you had your gallbladder removed?

Category LX Acne and unhealthy skin Excessive hair loss Overall sense or bloating Bodily swelling for no reason Hormone imbalances Weight gain Poor bowel function Excessively foul-smelling swe,1t

CategoryX Crave sweets during the day Irritable if meals arc missed Depend on co nee to keep going/get started Get light-headed if meals are missed Eating relieves fatigue Feel shaky,jittery, or have tremors Agitated, easily upset, nervous Poor me11101y, forgetful between meals Blurred vision

Category XJ Fatigue after meals Crave sweets during the day Eating sweets does not relieve ccavings for sugar Must have sweets a'fler meals Waist girth is equal or larger than hip gi1th frequent urination lncreased thirst and appetite Difficulty losing weight

O:i'IUSM,•l:i.-- Nl�R-·...J. P\ll.';f\l>d\1�l)fl<r>1,.,.J

SymptCNtr gro11p� hst(d 011 1/ris /om, on: 1101 imo,JcJ I<> be used .-,_,i a J,apmi,t of o.1�y dis MSc er eomlitfon.

Yes

Yes

/ No

/ No

Category XII Cannot stay asleep Crave salt Slow starter in the morning Afternoon fatigue Dizziness when standing up quickly Afternoon headaches Headaches with exertion or stress Weak nails

Category XIH Cannot fall asleep Perspire easily Under a high amount of slress Weight gajn when under stress Wake up tired eve□ after 6 or more how·s of sleep Excessive perspiration or perspiration with little

or no activiry

Category XJV Edema and swelling in ankles and \vriscs Muscle cramping Poor muscle endurance Frequenr urination Frequent thirst Crave salt Abnormal swearing from minimal activity Alteration in bowel regularity Inability to hold breath for long periods Shallow, rapid hre;:athing

Category XV Tired/sluggish Feel wld-hands, feet, all over Require excessive amoW1ts of sleep to fWJction properly Increase in weight even with low-calorie diet Gain weight easily Difficult, infrequent bowel movements Depression/lack of mo\ivation Moming headaches that wear off as the day progresses Outer third of eyebrow thins Thinning of haiT on scalp, face, or genitals, or excessive

bair loss Dryness of skin and/or scalp Mental slu.ggisbness

Category XVI Heart palpitations Tnward tremhling Tncrcased pulse even ac rest Nervous and emotional Insomnia

PARTIII

How many alcoholic beverages do you consume per week? ___ _

How many caffeinated beverages do you consume per day? ___ _

How many limes do you eat out per week? ___ _

How many times do you eat raw nuts or seeds per week'? ___ _

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

PART IV

Please list any medications you currently take and for what conditions:

Category XVI (Cont.)

Night sweats Difficulty gaining weight

Cate�ory XVll (Males OnfJ� Urination difficulty or dnobling Frequent urination Pain inside of legs or heels Feeling of incomplete bowel emptying Leg twitching at night

Category XVIIl (Males 011/y)

Decreased libido Decreased number of spontaneous morning erections Decreased fullness of erections Difficulty maintaining morning erections Spells of mental fatigue Inability to concentrate Episodes of depression Muscle soreness Decreased physical stamina Unexplained weight gain Tncrease in fat distribution around chest and hips Sweating attacks More emotional than in the past

Category XIX (Me11struati11g Females Only)

Perimenopausal Yes / No

Alternating menstrual cycle lengths Yes / No Extended menstrual cycle (greater than 32 days) Yes / No Shortened menstrual cycle (less than 24 days) Yes / No Pain and cramping dming periods Scanty blood flow Heavy blood flow Breast pain and sweUi11g during menses Pelvic pain during menses In·itable and depressed dming menses Acne Facial hair growth Hair loss/tl1inning

Category XX (Me11op1msal Females Only)

How many years have you been menopausal? ___ years

Since menopause, do you ever have uterine bleeding'? Yes / No

Hot flashes Mental fogginess Disinterest in sex Mood swings Depression Painful intercourse Shrinking breasts Facial hair growrh Acne Increased vaginal pain. dryness, or itching

Rate yonr stress level on a scale of 1-10 during the average week-:

How many times do you eat fish per week?

How many times do you work out per week?

Please list any natural supplements you currently take and for what conditions:

,. :.!l)t,1n,,u,�w-.. M R,el,=,,.llcw,'tld. =i.�1CM,\l'n.kilrfil�1\�,:

7 Scars

0 Surgery

□InternalMetal

\ I

TRAUMA HISTORY INFINITY WELLNESS CENTER

For online form, please type information into the appropriate area.

Please note areas where you have scars, even if they are very old or difficult to see. Don't forget C-sections, episiotomies, vaccination scars, surgeries, body piercings, tattoos, cosmetic surgeries, vasectomies, stretch marks, etc. Please note the approximate age you were when you got each scar.

Please note tbe location of any surgeries, including exploratory surgeries, laparoscopies etc. Please write the year of the surgery on the drawing.

Please note areas where there are any internal metal objects, such as surgical pins, metal plates, hip replacements etc.

DENT AL HISTORY

INFINITY WELLNESS CENTER

Name: ---------------

DIRECTIONS: Please describe what kind of dental work has been done on each tooth by noting the number and the procedure and the approximate age you were at the time. Please include the following if you have undergone these procedures:

□ Silver fillings□ Composite or porcelain fillings□ Gold fillings or crowns□ Root canals□ Veneers□ Bridgeo Dentureso Extracted teeth

Date: ---------

Don't Write Below this Line------------------------------------------------------------------------------

910111213141516

87654321

1718192021222324

3231302928272625

Directions: Please select the body type which most closely resembles you.

,ft

\� t \

D Tend to have a small chest relative to the rest of the body; a forward head carriage; rounded shoulders and "baby fat" all over the body.

D Tend to have extra weight on the thighs and upper hips, a curvy waist and tapering lower arms and legs. Also lends to carry fat on the stomach, mainly below the belly button.

D Tend to have a sturdy body with a straight flat back and extra weight carried in the front.

� ,r

D Tend to have a small upper body compared to the lower body, with a small waist and "saddlebags" on the outer thighs. Extra weight tends to be carried behind ( especially on the rear end) with a relatively flat stomach

Section II: Risk of Exposure Rate each of the following situations based upon your environmental profile for the past 120 days.

Note the corresponding number for questions l6a-16fbelow and enter the total.

Never Rarely Monthly Weekly Daily

a. How often are strong chemicals used in your home?

(disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc.) 0 I 2 3 4 b. How often are pesticides used in your home? 0 1 2 3 4 c. How often do you have your home treated for insects? 0 1 2 3 4

d. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home or office?

0 1 2 3 4

e. How often are you exposed to nail polish, perfume, hairspray, or other cosmetics? 0 1 2 3 4

f. How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes? 0 l 2 3 4

Total:

Note the corresponding number for questions l 7a-l 7b below and enter the total.

No Mild Change Moderate Change Drastic Change

a. Have you noticed any negative change i.n your health since you moved into yow- home or apartment? 0 l 2 3

b. Have you noticed any change in your health since you started your new job? 0 l 2 3

Total: ____ _

18. Answer yes or no, noting the corresponding number for questions 18a-18d and enter the total.

No Yes a. Do you have a water purification system in your home? 2 0 b. Do you have any indoor pets? 0 2 c. Do you have an air purification system in your home? 2 0 d. Are you a dentist, painter, farm worker, or construction worker? 0 2

Total:

Section II Total:

Grand Total (Section I & Section II)

Add up the numbers to arrive at a total for each section, and then add the totals for each section to arrive at the grand total.

If any individual section total is 6 or more, or the grand total is 40 or more, you may benefit from a Clinical Purification TM

program.

Adapted with permission from the author of Clinical Purification™: A Complete Treatment and Reference Manuai Dr. Gina L. Nick.

Child Neurotransmitter & Nutrition Questionnaire (CNNQ)

Name: Age: Sex: Date:

* Please type in the appropriate number "O - 3" on the questions below. 0 as the least/never to 3 as the most/always.

SECTION; GENERAL • Does your child have any food sensitivities or allergies? (please list)

• List your child's 4 healthiest foods eaten regularly.

• List your child's 4 unhealthiest foods eaten regularly.

• How many times a week does your child eat candy? ___

• How many times a week does your child drink soda pop? ___

• Please list the top 4 foods your child craves regularly?

• List the medication(s) your child is currently prescribed and over the counter.

• Do you find it difficult as a parent to have your child on a special diet?

SEC110N: A (K52) • Does your child eat pasta, breads, and breaded foods?

• Does your child have symptoms (fatigue, hyperactivity, etc.)

after eating wheat foods?

• Does your child eat dairy products?

• Does your child have symptoms (fatigue, hyperactivity, etc.)

after eating dairy products?

SECTION: B (K53) • Does your child eat fried fish?

• Does your child eat roasted nuts or seeds?

• Is your child missing essential fatty acid rich foods in

his/her diet? (for example: avocadoes, flax seeds, olives)

(mark "O" if

present, "3" if missing)

• Does your child eat fried foods?

SECTION: C (K34) • Is your child's mental speed slow?

• Does your child have difficulty with learning or memory?

• Does your child have difficulty with balance and coordination?

SECTION: D (K16) • Does your child have stress?

• Does your child not have enough sleep and rest?

(mark "3" ifnotenough)

• Does your child not have regular exercise?

(mark "3" if no exercise)

• Does your child feel overly worried and scared?

SECTION: E CK16. K51) • Does your child have temper tantrums?

• Does your child exhibit wild behavior?

• Does yom· child frequently yell or scream for

unnecessary reasons?

• Does your child have an inability to nap or sleep when

physically exhausted? (mark "3" if unable)

• Is your child overly talkative?

• Does your child fidget and squinn when seated?

• Does your child run and climb excessively when it

is inappropriate?

• Does your child have difficulty playing quietly or

engaging in leisure activities?

SECTIQN: F (K51} • Does your child get excited easily?

• Does your child have anxiousness and panic for

minor reasons?

• Does your child feel overwhelmed for minor reasons?

• Does your child find it difficult to relax when she/he

is awake?

• Does your child have disorganized attention?

SECTIOIS: G <K50) • Does your child seem depressed?

• Does your child have mood changes with

overcast weather?

• Does your child have symptoms of inner rage?

• Does your child seem uninterested in games or hobbies?

• Does your child have difficulty falling into deep

restful sleep?

• Does your child seem uninterested in friendships?

• Does your child have symptoms of unprovoked anger?

• Does your child seem uninterested in eating?

SECTION: H (K49) • Does your child have difficulty handling stress?

• Does your child have anger and aggression while

being challenged?

• Does your child feel tired even after long sleeps?

• Does your child tend to isolate from others?

• Does your child get distracted easily?

• Does your child have constant need and desire for

candy and sugar?

• Does your child have disorganized attention?

SECTIQN: I (K4S} • Does your child have difficulty with visual memory?

• Does your child have difficulty remembering locations?

• Does your child have fatigue or low endurance for

learning activities?

• Does your child have difficulty with attention or low

attention span or endurance?

• Does your child have slow or difficult speech?

• Does your child have uncoordinated or slow movement?

Symptom groups listed in lhls flyer are not Intended to be used as a diagnosis of any disease condition. For nutritional purposes only

All Rights Reserved, Copyright@ 2009, Oatis Khanal:ian SMGECNNQ01 (0709).INDD

Medication History* For each category, please note the number for a.ny or the following medications you have taken in the past or are currently taking

in the text box at the top left of each category.

Noradrenergic and Specific Serotonergic Antidepressants (NaSSAs)

□ 1. Remeron�

□ 2. Zispin"

□ 3. Avan;,.a'

□ 4. Norsct•

□ 5. RemergiP

□ 6. Axi�

Tricyclic Antidepressants (TCAs}

□ 1. Elavil2

□ 2. Endep"'

□ 3. Tryptanol•

□ 4. Trcpiline•

D 5. Asendin•

D 6. Asendisl

0 7. Defanyl._

D 8. Demolox°'

0 9. Moxadil�

0 11. Anafranil'

0 12.Norprnmia"

D 13.Pertofraue�

□ ·14. maden'"

□ 15.Pro1ruaden"

D 16. Adapin"

□ 17.Sinequan�

□ 18. Tofrann•

D 19.Jaruuninc._

D 21Gamanil•

□ 22.Aventyl"'

□ 23.Pamelor•·

D 24.0pipramol"

D 25.Vi1•actil�

D 26.Rhotriminc'

D 27.Surrnontil�

D 28.Norpramin"

Selectlve Serotonin Reuptake Inhibitors (SSRis)

D 1 Paxi1• D 15. Seromex,,..

□ 16. Seronil"

0 17. Sarafem•

D 18. Fluctinx

□ 2. Zoloft''

0 3. Prozac•·

D 4. Celexa"'

□ 5. Le1mpro"

□ 6. Gsert1ae

D 7. Luvo;-.�"

□ 8. Cipramil'"

D 9. Emocal"

0 11. Scropramt

D 12. Cipralex'-

D 13. Fonte"'

□ 19. Faverin�

D 21. Scroxat�

D 22. Aropa.,'

0 23. 0croxat''

D 24.Rexetin"

D 25.ParoxaJ1

D 26.Lustral"

D 27.Serlain•

□ 14. Priligy"

Serotonin-Norepinepllrine Reuptake Inhibitors (SNRls)

0 1. Effexor4'

D 2. Pristic(�

D 3. Meridia"

□ 4. Scrzonc•·

□ 5. 0alcipran'

□ 6. Cymbalta�

Selective Serotonin Reuptal,e Enhancers (SSREs)

0 1. Stablon"'

0 2. Coaxil' □ 3. Tatinol�

,,:.1,,ri-..�-- ."IIIN:;J, .. i'-,••»L --"1.Uh"H.IJIJ.-'IV'll,1,p

Monoamine Oxidase Inhibitors (MAOis)

□ 1. Marplan'"

0 2. Aurorix"'

D 3. Mnnerix"'

□ 4. Moclodura�

D 5. Nardil.,

0 6. Adeline•

□ 7. Eldepry l"'

D 8. Azilcct"

D 9. Marsilid"'

0 11. lp{Ozid"

□ 12. lpronid�

D 13. Rivivol"

□ 14. Propilniazida�

□ 15. Zyvox• 0 16. Zyvoxid"

Dopamine Receptor Agonists

D 1. Mirape;-...,

□ 2. Sifrol"'

D 3.Requip"'

Norepinepbrine-Dopamine Reuptake lohibitors (NDRJs)

0 1. Wellbulrin XL 1

02 Dopamine .Receptor Blockers (antipsychotics)

D 1. Thorazine.-

D 2. Prolix.in"'

0 3. Trilafon•

□ 14. Acuphase�

0 15. Haldol"

□ 16. 0rap•

D 17. Clozaril�

D 18. Zyprexa"'

□ 19. Zydis"'

D 21. Seroquel XR"

0 22. Geodon•

□ 4. Compazine"

0 5. Mellaril"'

□ 6. Stelaz.ineb

□ 7. Vcsprin"

D 8. Nozinan 1'

□ 9. Depixol'·

D 11. Navam;i• □ 23. Solian"

D 24.0lnvcga�

0 25. Abili:fy� 0 12. Fluanxol�

0 13. Clopixol"'

GABA Antagonist Competitive Binder

□ 1. Romazicon"

Agonfat Modulators of GABA Receptors (benzodiazepines)

D 1. Xana'i:' D 11. Dalmane"'

0 12. Ativan·•

0 13. Loramef•'

□ 14. Sedoxil�

0 15.Dormicum"

D 16. Sera_x�

D 17. Restoril"'

0 18. Ha!cion•

□ 2. Lexotanil"

D 3. Lexotan1

D 4. Librium"'

D 5. Klonopin"'

□ 6. VolJUm-»

□ P7. rosom"'

0 8. Rohypno!•

D 9. Magadon"

Agonist Modulators of GABA Receptors (non-benzodiazepines)

□ 1. Ambien CR�

0 2. Sonata�

D 3. Lunesta"

0 4. lmovane·•

Acetylcholioe Receptor Agonfats

D 1. Urecholine" D 4. Jsopto�·

0 2. Salagen"

D 2. Evoxa& □ 5. Nicolonc

Acetylcboline Receptor Antagonists (antimuscarinic agents)

D 1. AtroPen�

□ 2. Scopacc"

□ 3. Atroven�

0 4. Spiriva"

Acetylcholine Receptor Antagonists (ganglionic blockers)

0 1. lnversine� D 3. Hexametbonium

□ 2. Nicotine (hi� doses) 0 4. Arfonad"'

Acetylcholine Receptor Antagonists (neuromuscular blockers)

□ 1. Tracrium·� □ 2. Nimbex"

□ 3. Nuromax"

0 4.Metubine•

D 5.Mivacron•·

0 6.Pavulon•

0 7. Zemuron"'

D 8. Anectim:"

D 9. Tubocurarine'"

□ 11. Norcuron"'

D 12. Hemicholinium-3"

Acetylcholinesterase Reactivators

D 1. Protopam"'

Cholinesterase Inhibitors (reversible)

□ 1. Ariccpl� D 2. Razadyne"

□ 3. Exelon�

0 4. Cognex·•

D 7. Enlon�

D 8. Prostigmin�

□ 9. Antilirium"

D 11 Mestinon� □ 5. THC D 6. Carbama1e ioscctic1des

Cholinesterase Inhibitors (irreversible)

□ 1. Echothiophate

□ 2. lsoflurophate

D 3. 0rganophosphatc insecticides

D 4. 0rganophosphate--containing nerve agerns