Neuroptimal® Progress Tracker
Name
First Name
Last Name
Session #
email
Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Rate each as it affects you on a scale of 0-10
Rows
(0=No issues, 10=Severely affects me)
1. Trouble falling asleep
2. Wake up during the night & can't fall back asleep
3. Wake up too early
4. Sleep too much
5. Nightmares
6. Snoring
7. Wake up & start worrying
8. Shallow breathing/shortness of breath
9. Holding your breath
10. Gut issues
11. Sensitive digestion
12. Constipation
13. Poor appetite
14. Headaches when under stress
15. Migraines
16. Can't remember what I just did
17. Memory problems
18. Blocked on words
19. Pain in muscles joints
20. Feeling tired or having little energy
21. Don't feel comfortable in my body
22. Difficulty paying attention
23. easily distracted when trying to focus
24. Difficulty organizing/scheduling
25. Difficulty prioritizing tasks
26. Trouble concentrating on things, such as reading or watching television
27. Food habits are hard to control
28. Binge eat/drink
29. Overspend
30. Make a lot of mistakes
31. Losing train of thought
32. Can't sit still
33. Verbally impulsive
34. Inverting numbers/letters
35. Body or vocal tics
36. Mood swings
37. Irritable
38. Feel anxious
39. Feel depressed
40. Feel sad
41. Feel hopeless
42. Feel numb
43. Feel like the world isn't a safe place
44. Feel like others are against me
45. Panic attacks
46. Have repetitive/persistent worries
47. Obsessive thoughts
48. Need to repeat actions over and over
49. Phobias
50. Feel angry/have angry outbursts
51. Impulsive/overwhelmed
52. Want to hide
53. Feel frozen in my life
54. Feel like I just can't win/ nothing goes my way
Rate each item on a scale of 0-10
Rows
(0=No issues, 10=Severely affects me)
1. How difficult have these issues made it for you to do your work?
2. How difficult have these issues made it for you to take care of things at home?
3. How difficult have these issues made it for you to get along with other people?
List the top 4 areas you would like to see improvements:
Comments/Notes:
Submit
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