Concerns Checklist

Concerns Assessment Checklist
Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where are you in your training?
Please rate your quality of life on the scale below:

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best

Below is a list of common concerns. Please answer only those that have applied to you over the last 7 days. To the right of the items that apply, enter the Duration: how many minutes or hours does it last? Intensity: the level you experience this on a scale of 0-10 (10 being most intense). Frequency: how many times over the last 7 days this has happened?

Rows	Duration (How long does this last?)	Intensity (not intense 0--10 very intense)	Frequency (How often in the last 7 days?)
Itchy or irritated nose, sneezing
Wheezing
Catch cold to often
Run down
Tired
Awake too long when you go to bed
Waking up during the night
Waking up before you want to
Difficult to wake up in the morning
Bad Dreams
Difficulty breathing at night
Out of bed but not knowing how you got there
Skin difficult to manage
Hair weaker or less lustrous than you'd like
Nails weak, flaking, or tearing
Blurry vision at times
Areas where you can't see anything
Spots floating in front of you
Difficult to hear
Ringing in your ears
Ears hurt inside
Smells seem different or lost
Nose gets blocked
Grinding your teeth
Things taste different
Voice hoarse or sore
Can't get enough air
Heart too fast or jumpy
Pulsing or throbbing in your head
Heart skips a beat
World spinning around you
Might throw up
Tummy hurts
Gassy, bloated
Sensitive digestion
Upset stomach
Difficulty going to the bathroom
Eat when not hungry, or not feeling hungry
Trouble eating sweets
Urges to eat sweet things
Sensitive to heat or cold
Slowed down or speeded up
Moody at certain times of the month
Hot flashes
Problems from being of a "certain age"
Not interested in your partner
Too interested in your partner or other people
Stiff and sore
Areas that really hurt when touched
Muscles hurt
Fatiqued
Pains in your head
Going to pass out
Lose consciousness
Difficult to remember things
Difficult to find your words
Difficulty reading
Difficult to speak sometimes
Shaky
Weak
Too active
Can't balance on one leg
Moving your head or saying words you don't intend
Difficulty paying attention
Easily Distracted
Make a lot of mistakes
Disorganized
Difficult to complete tasks
Lose your train of thought
Difficult to complete studies or work
get into trouble at school or work
Mix up numbers or letters sometimes
Difficult to know how things fit together
Difficulty with some subjects
Need to go to the bathroom but hard to start
Lose your urine sometimes
Difficult to control going to the toilet
Stinging sensations when going to the bathroom
Drink too much sometimes
Smoke cigarettes
Concerns about eating
Need caffeine to get going
enjoy marijuana
Habits that concern you
Moody
Feeling low or flat
Feel sad
Concerned about things
Feel terrified sometimes
Mull about things
Thoughts you'd like to stop but can't
need to do things over and over
Eat more food than you can comfortably eat
Carful to never eat too much
Make yourself throw up
Difficult to do things you'd like to do
Others are against you
Get into trouble for your behavior
Feeling angry
Overwhelmed

Please use this space to list any additional items not represented above. Please Include their (D) Duration, (I) Intensity, and (F) Frequency and limit to only the last 7 days!
Example: "Uncontrolled shaking of hands: D = 15 mins, I = 8, F= 2"
How are the items in the list above or your added items affecting your daily life?
Example: "I have not been able to attend work (or school) due to...."
How will we know this is working for you? What will be changing or happening for you? What do you "wish" for yourself?
Example: "I will be able to complete a task I have started in a timely manner." or "I will be able to let go of an intrusive thought more quickly"
Would you like a copy of your submission? Please enter your email address below.
Email
example@example.com
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