Concern Assessment Form
You will fill this form out before you start sessions and along the journey of your training. This helps us first establish a baseline of how you are coping and then how you are improving with training.
Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where are you at in your training?
*
This is my first session (PRE)
I'm doing regular sessions (ONGOING)
This is my last session for a while (POST)
How do you rank your current Quality of Life on a scale of 0-10
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
You will next rate common concerns
Provide the intensity and frequency for only items you experienced in the last 7 days. Leave all others blank. Intensity is scored on a 0-10 scale with 10 high intensity. Frequency is how many times over the seven days have you experienced this intensity.
Example
Intensity
Frequency
Item name
7
5
Appearance and Skin:
Rows
Intensity
Frequency
Skin hard to manage
Hair feels thin or dull
Nails break, flake, or tear easily
Rashes or itchy skin
Body Regulation and Hormonal Shifts:
Rows
Intensity
Frequency
Sensitivity to heat or cold
Hot Flushes
Mood or energy shifts during certain times of the month
Feeling unsettled during physical or hormonal changes
Body Sensations and Muscle Tension:
Rows
Intensity
Frequency
Feeling stiff or sore
Muscles feel tense or painful
Areas of body are sensitive to touch
General aches or head discomfort
Digestion and Elimination:
Rows
Intensity
Frequency
Stomach sensitivity or pain
Digestive discomfort
Gas, bloating, or upset stomach
Feelings of nausea
Trouble with digestion or elimination
Difficulty starting or controlling urination
Discomfort when using the toilet
Eating Patterns and Cravings:
Rows
Intensity
Frequency
Eating without feeling hungry
Cravings that feel hard to control
Eating past the point of comfort
Overly controlling food intake
Changes in appetite or eating habits
Emotional Well-Being:
Rows
Intensity
Frequency
Feeling low, flat, or sad
Feeling overwhelmed or anxious
Quick to feel angry or reactive
Emotional ups and downs
Overthinking
Repetitive thoughts
Feeling misunderstood or judged
Difficulty managing behavior
Fear or unease without a clear cause
Energy and Resilience:
Rows
Intensity
Frequency
Often tired or run down
Low stamina
Stressful events feel hard to move on from
Feeling shaky or weak
Feeling sluggish or restless
Energy crashes in the afternoon
Habits:
Rows
Intensity
Frequency
Using substances like nicotine, alcohol, or drugs
Relying on caffeine to get going
Habits feel hard to shift
Coping strategies feel out of sync with intentions
Trouble starting "good" habits
Heart, Breath, and Balance:
Rows
Intensity
Frequency
Feeling breathless or short of air
Heart feels fast, jumpy, or irregular
Head often hurts
Feeling lightheaded or dizzy
Fear of fainting or passing out
Trouble maintaining balance
Mental Clarity and Focus:
Rows
Intensity
Frequency
Difficulty concentrating
Easily distracted
Trouble completing tasks
Thoughts frequently trail off
Feeling forgetful or foggy
Trouble with reading or comprehension
Difficulty finding words
Frequent mistakes
Feeling disorganized or scattered
Trouble understanding how things fit together
Mixing up numbers or letters
Difficulty starting or completing tasks
Relationships and Connections:
Rows
Intensity
Frequency
Lack of interest in physical intimacy
Preoccupied with attraction or relationships
Struggling to feel connected
Difficulty being emotionally available
Difficulty making or keeping friends
Feeling disconnected from others
Trouble trusting others
Struggling to communicate openly
Feeling easily hurt or rejected
Sensory Sensitivities:
Rows
Intensity
Frequency
Ringing in the ears
Ear discomfort or sensitivity
Changes in smell or taste
Blurry vision or floaters
Occasional difficulty hearing
Changes in vision
Sensitivity to certain textures
Nose often blocked or irritated
Frequent sneezing or itchy nose
Sleep and Rest:
Rows
Intensity
Frequency
Trouble falling asleep
Waking up during the night
Waking earlier than intended
Difficulty waking up in the morning
Vivid or unsettling dreams
Restless sleep
Sleepwalking, talking or nighttime confusion
Urinating during sleep
Speech and Communication:
Rows
Intensity
Frequency
Trouble getting words out clearly (physically stumbling or slurring)
Hard to express thoughts clearly or be understood
Saying things not meant to be said
Voice feels hoarse or strained
Interrupting others a lot
Work, School, and Daily Functioning:
Rows
Intensity
Frequency
Difficulty holding a job or staying employed
Trouble keeping up with responsibilities
Challenges with time management or deadlines
Struggling to stay organized
Difficulty maintaining focus throughout the day
Feeling overwhelmed by everyday tasks
Difficulty completing work, homework or assignments
Please elaborate on your top 3-5 rated aspects from above. Describe below how they are directly affecting your life.
*
Is there anything to add that was not included on the list above? If yes, please list including their Intensity (I), and Frequency (F) ratings.
If this will be your first time doing neurofeedback and you could look into the future, how do you hope this training benefits you? If you are training regularly, please use this space to tell us about the shifts you are experiencing.
Email
example@example.com
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