Cognitive Function Questionnaire

Cognitive Function Questionnaire

For Neurofeedback and and Audio-Visual Entrainment
Client Name:

First NameLast Name
Date:

MonthDayYear
Session Number:
Please rate the following behaviors/skills on a scale of 1 thru 10, using all the numbers in between.

1 = Minor problem
2, 3, 4 = Problem - But I work around it
5 = Definitely a problem - Can't ignore but can live with it
6, 7, 8 = Big problem - Blocks who I want to be
9, 10 = Huge problem - Don't know what to do / overwhelmed / panic attacks

Please rate how often this happens:

	1	2	3	4	5	6	7	8	9	10
I have trouble forming thoughts
I have restless sleep / wake early / can't sleep
My thinking has been slow
I have trouble concentrating
I feel hesitant and uncertain
I have trouble finding familiar places
I have trouble remembering where I put things (wallet, keys, etc.)
I am tired during the day
I have trouble remembering new information like phone numbers or simple instructions
I have trouble recalling a name of an object when I talk to someone
I have trouble expressing myself with words
I have used a wrong word when I have referred to an object
I do not remember what I have heard
I've walked into a room and forgotten what I meant to get or do there
I work really hard to pay attention
I can not stay on task
I am impulsive and/or obsessive
I have a difficult time participating in daily family discussions
I struggle with anxiety and/or repetitive thoughts
I often feel depressed, sad or worried
It's hard for me to engage with people
I have trouble controlling my anger and/or emotional outbursts
I struggle with motivation and follow through on tasks
It's hard for me to feel calm and relaxed