Attention Assessment (Teen/Adult)

Attention Assessment (Teen/Adult)
Client Name:

First NameLast Name
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email:
example@example.com
Session Number:
Rate your everyday stress level on a scale of 1-10 (1 is calm and 10 is completely out of control):
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:

Rows	1	2	3	4	5	6	7	8	9	10
Focus / concentrate in school or at work
Fidgety, restless, antsy, impatient
Transition from one activity to another
Distractible
Impulsive behavior without thinking
Take unsafe risks
Lose things
Overwhelmed
Disorganized work habits
Accident prone
Don't understand other person's emotions or point of view
Don't respond to other people's feelings
Sensitive to certain sounds
Insensitive to pain/heat/cold
Super sensitive to pain
Super sensitive to touch
Frustration or anger outbursts
Can't calm down after anger or excitement
Trouble getting to sleep at night
Waking up at night
Headaches or Migraines
Nail biting
Repetitive negative thoughts/ideas
Anxiety, fear, apprehension, panic
Sweating when it's not hot
Feel helpless
Trouble remembering things - mind goes blank, forgetful
Annoyed, angered, irritated
Feel confused
Cry easily
Blame yourself for others' mistakes
Blame others for your mistakes
Feel critical of others
Unable to figure out boundaries between self and others
Feel lonely, separate, sad
Prefer to be alone
Difficulty making friends
Lack control of intake of food, alcohol, drugs
Feelings of guilt, shame
Easily hurt
Feel inferior to others
Feel hopeless about the future
Depressed, feel flay, withdrawn
Feel resistant
Feel self-conscious
Feel you are watched or talked about by others
Feel people are unfriendly or dislike you
Feel people will take advantage if you let them
Unusual body feelings