Adult Checklist
First Name:
Last Name:
Today's Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
COMMON PROBLEMS
No single question is critical. Feel free to skip items that are not pertinent to you.
Attention Problems
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Miss important information
Don’t listen well
Make careless errors
Short attention span
Disorganized
Procrastinate
Easily distracted
Difficulty staying on task
Get bored easily
Risk-taking behavior
Daydream/space-out
Low energy/sleepy in the daytime
Difficulty making decisions
Underachiever
Trouble following directions
Difficulty remembering
Works best under pressure
Easily frustrated
Act before thinking/impulsive
Can’t see consequences of behavior
Lose things
Difficulty sitting quietly/restless
Talk excessively/interrupts others
Impatient
First Name:
Last Name:
Moods/Emotions
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Grouchy, irritable
Fearful/nervous/jumpy
Excessive worry
Sad or moody
Feel hopeless/helpless
Racing mind/mind never stops
Easily upset/tearful
Lose temper easily/Anger
Spiteful/vindictive/holds grudges
Excessively stubborn
Lie, cheat, steal
Blame others
Hard to calm once triggered
Hypervigilant
Panic attacks
Social anxiety
Obsessive, compulsive (OCD)
Apathetic/unmotivated
Inflexible/avoids change
Lack interest in activities
Perfectionist
Poor social skills
Withdraw when stressed
Lack empathy
Poor self-esteem
Loud unmodulated voice
Eating disorder history
First Name:
Last Name:
Other Cognitive Issues
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Poor memory
Difficulty remembering names
Dislike reading/difficulty reading
Poor reading comprehension
Trouble with math
Poor handwriting
Poor sense of direction
Difficulty listening and taking notes
Overwhelmed easily
Difficulty saying what I think
Can’t summarize and explain simply
Easily confused
Monotone speech
Sensitive to sound
Chronic Pain
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Migraines/headaches
Jaw pain
Neuropathy
Neck pain
Back pain
Sciatica
Fibromyalgia
Other pain (describe)
First Name:
Last Name:
Physical
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Food sensitivities/Allergies
Hypoglycemia (low blood sugar)
Reactive and sensitive to environment
Nausea or dizziness
Asthma
Chronic fatigue
Autoimmune issues
Tinnitus (ringing in ears)
History of ear aches or sinus issues
History of stomach complaints
History of seizures
Chronic constipation
Possible mold exposure
Poor coordination, clumsy, poor motor skills
High blood pressure
Diabetes
Heart issues
Tremors
Poor balance
Hormonal
Rows
No
Yes
Comments
Hypothyroid (underactive thyroid)
Hyperthyroid (overactive thyroid)
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Hot flashes or night sweats
PMS
Hair loss
Low energy
Other endocrine issues
Sleep
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Restless sleep
Waking with anxiety or depression
Bad dreams or nightmares
Excessively vivid dreams
Sleep apnea
History of sleepwalking
Talking in sleep
Teeth grinding
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