Problem & Symptom Checklist for Neurofeedback Assessment

Self Report Problem & Symptom Checklist
In the following lists below, please mark any problems (symptoms) that you have experienced in the past month.

* All information you provide will be treated as private and confidential. *

Pre-Existing Conditions

In the area below, please mark any diagnoses you have received from a medical provider.

Last 6 Months:

	Diagnosis/Condition	Year Diagnosed	Medication(s) Currently Taken	Receiving Treatment From a Provider ?	Is this diagnosis/condition still active?
1)
2)
3)
4)
5)

Over Lifetime:

	Diagnosis/Condition	Year Diagnosed	Medication(s) Currently Taken	Receiving Treatment From a Provider ?	Is this diagnosis/condition still active?
1)
2)
3)
4)
5)

	None	Very Mild	Mild	Moderate	Severe
Lack of motivation
Inattention
Daydreaming
Poor concentration
Misses important Information
Makes careless errors
Short attention span
Disorganized
Procrastinates
Easily distracted
Difficulty staying on task
Gets bored easily
Dislikes sustained mental efforts
Stimulus seeking
Thrill seeking
Trouble following direction
Difficulty with remembering/ recall
Frustrated easily
Competing thoughts / too many thoughts
Acts before thinking / Impulsive
Trouble changing focus
Loses things
Fidgets/ Difficulty sitting quietly
Trouble finishing what you started
Excessive talking / interrupts others
Impatient

	None	Very Mild	Mild	Moderate	Severe
Dyslexia
Indecisiveness
Poor word fluency
Poor sequential processing
Poor reading comprehension
Poor spelling
Dislike reading / find it challenging
Difficulty decoding words
Trouble with math
Poor understanding of algebra
Poor understanding of geometry
Poor handwriting
Poor sense of direction
Difficulty listening and taking notes
Overwhelmed easily with “too much” information
Difficulty saying what you think
Difficulty with written expression
Inability to summarize & explain simply
Poor at planning and organizing
Easily confused
Monotone speech
Sensitive to sound
Difficulty identifying left from right
Poor fine motor skills
Poor visual-spatial skills

	None	Very Mild	Mild	Moderate	Severe
Excessive worry
Feeling low, helpless & hopeless
Irritability
Feelings easily hurt
Perfectionist
Remorseful after tantrums
Cries easily (feelings hurt)
Rumination
Guilt
Passive
Suicidal thoughts
Suicidal actions
Grumpy, irritable
Performance anxiety
Shy
Seasonal affective disorder (SAD)
Fidgets
Tired
Obsessive thoughts
Obsessive behaviors
Explosive/ angry/ lashes out
Loses temper easily
Oppositional/argues
Spiteful/ vindictive/ holds grudges
Excessively stubborn
Jealous/envious
Lies, cheats, steals
Road rage
Deliberately annoys others
Blames others
Aggressive/ initiates conflict
Hard to calm once triggered
Mood swings

	None	Very Mild	Mild	Moderate	Severe
Hypervigilant
Panic attacks
Social anxiety
Apathetic/ unmotivated
Poor social skills
Poor social awareness
Poor eye contact
Inflexible/ avoids change
Lacks interest in activities
Withdraws when stressed
Lacks empathy
Manipulative
Self-conscious, easily embarrassed
Hates self
Self-harm behaviors
Binge eating
Anorexia
Bulimia
Bipolar disorder
Dissociative identity disorder (DID)
PTSD/ Posttraumatic stress disorder
Developmental trauma
Attachment disorder (history)
Fear
Mania
Rages
Paranoia
Anxiety
Dissociation
Shame
Lacks body awareness (pain, discomfort, appetite)
Hair pulling/ twilling
Nail biting/nervous habit

	None	Very Mild	Mild	Moderate	Severe
Night sweats
Frequent waking (without agitation)
Sleep lightly
Sleeping too much
Sleep apnea
Snoring
Not rested after sleep
Waking early
Night terrors
Nocturnal myoclonus (jerking or moving while asleep)
Sleepwalking
Sleep talking
Narcolepsy (falling asleep frequently or suddenly)
Too busy to sleep (manic quality)
Bed-wetting during sleep (Enuresis)
Sleep paralysis (when awaking: temporary inability to move or speak / still in dream state)
Difficulty falling asleep (mind busy)
Difficulty falling asleep (even if mind is quiet)
Hot flashes during sleep
Physically restless sleep
Nightmares (bad dreams)
Teeth grinding
Restless leg
Vivid dreams
Clenching jaw
Waking with agitation
Vigilant sleep

General Information

	None	Very Mild	Mild	Moderate	Severe
Food sensitivities
Hypoglycemia (low blood sugar)
Nausea
Dizziness
Allergies
Asthma
Chronic fatigue
Chemical sensitivity
History of ear aches
History of sinus issues
History of stomach issues
Constipation
Diarrhea
Enuresis (urinary incontinence)
Irritable bowel syndrome (IBS)
Poor appetite
High blood pressure
Low blood pressure
Heart issues
Postpartum depression
Severe PMS (mood swings/cravings)
Chronic fatigue syndrome
Hypothyroid
Hyperthyroid
Diabetes (In comments- Type 1 or Type 2)
Lupus
Rheumatoid arthritis
Crohn’s disease
Multiple sclerosis
Irregular menstrual periods
Menopausal hot flashes
Skin allergies, eczema
Heart palpitations
Sugar cravings

	None	Very Mild	Mild	Moderate	Severe
Fibromyalgia
Tension headaches
Migraines
Jaw tension
Chronic aching pain
Chronic burning pain
Chronic throbbing pain
Chronic shooting pain
Sciatic pain
Reflux
Emotional reactivity to pain
Neuropathy
Joint pain
High pain threshold
Low pain threshold

	None	Very Mild	Mild	Moderate	Severe
Concussion
Traumatic brain injury w/brainstem injury
Left-brain -Traumatic brain injury
Right brain -Traumatic brain injury

	None	Very Mild	Mild	Moderate	Severe
Generalized seizures
Left-brain seizures
Right-brain seizures
Absence seizures (petit mal)
Tonic-clonic seizures (grand-mal)
Temporal lobe epilepsy
Stroke
Vertigo
Motion sickness
Tinnitus
Tics
Tremors
Dystonia
Poor balance
Poor coordination
Nervous habits/laugh
Right-body paralysis or paresis
Left-body paralysis or paresis