Cognitive Symptom & Difficulty Self-Assessment
Score each item below from 0 (Nil issues) to 3 (Severe issue). Use the scale legend as a guide. Complete all topics and view your total score at the end.
Name
*
First Name
Last Name
Date Of Birth
*
SYMPTOM: Please rate each symptom below.
Score each topic from 0 to 3.
Scale Legend: 0 = Nil issues, 1 = Mild issue, 2 = Moderate issue, 3 = Severe issue.
Slow thinking
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Mentally exhausted
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Fatigue
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Easily distracted
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Feeling spacey, confused, lost or day dreaming
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Easily annoyed
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Feeling anxious and stressed
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
DIFFICULTY: Please rate your level of difficulty for each item below.
Score each one from 0 to 3.
Understanding words when reading
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Understanding new information
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Recalling names of people and objects
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Concentrating
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Organising my thoughts
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
Understanding what people are telling you
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
With thoughts racing
*
Nil issues
0
1
2
Severe issue
3
0 is Nil issues, 3 is Severe issue
TOTAL SCORE (Sum of all scores above)
For further cognitive testing, visit:
Aptitude Test - Cognitive
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