Master Hemispheric Checklist

Master Hemispheric Checklist
Name

First NameLast Name
Date of Birth

MonthDayYear
Phone Number

Area CodePhone Number
Email
example@example.com
Please check the appropriate box in "Start of Program".
Motor characteristics of a right brain delay
Clumsiness and an odd posture

Start of program4 weeks8 weeks12 weeks
Poor coordination

Start of program4 weeks8 weeks12 weeks
Not athletically inclined and has no interest in popular childhood participation sports

Start of program4 weeks8 weeks12 weeks
Low muscle tone - muscles seem kind of floppy

Start of program4 weeks8 weeks12 weeks
Poor gross motor skills, such as difficulty learning to ride a bike and/or run and/or walks oddly

Start of program4 weeks8 weeks12 weeks
Repetitive/sterotyped motor mannerisms (spins in circles/flaps arms)

Start of program4 weeks8 weeks12 weeks
Fidgets excessively

Start of program4 weeks8 weeks12 weeks
Poor eye contact

Start of program4 weeks8 weeks12 weeks
Walks or walked on toes when younger

Start of program4 weeks8 weeks12 weeks
TOTAL:
Motor characteristics of a left brain delay
Fine motor problems (poor or slow handwriting)

Start of program4 weeks8 weeks12 weeks
Difficulty with fine motor skills, such as buttoning a shirt

Start of program4 weeks8 weeks12 weeks
Poor or immature hand grip when writing

Start of program4 weeks8 weeks12 weeks
Tends to write very large for age or grade level

Start of program4 weeks8 weeks12 weeks
Stumbles over words when fatigued

Start of program4 weeks8 weeks12 weeks
Exhibited delay in crawling, standing, and/or walking

Start of program4 weeks8 weeks12 weeks
Loves sports and is good at them

Start of program4 weeks8 weeks12 weeks
Good muscle tone

Start of program4 weeks8 weeks12 weeks
Poor drawing skills

Start of program4 weeks8 weeks12 weeks
Difficulty learning to play music

Start of program4 weeks8 weeks12 weeks
Likes to fix things with the hands and is interested in anything mechanical

Start of program4 weeks8 weeks12 weeks
Difficulty planning and coordinating body movements

Start of program4 weeks8 weeks12 weeks
TOTAL:
Sensory characteristics of a right brain delay
Poor spatial orientation - bumps into things often

Start of program4 weeks8 weeks12 weeks
Sensitivity to sound

Start of program4 weeks8 weeks12 weeks
Confusion when asked to point to different body parts

Start of program4 weeks8 weeks12 weeks
Poor sense of balance

Start of program4 weeks8 weeks12 weeks
High threshold for pain - doesn't cry when gets a cut

Start of program4 weeks8 weeks12 weeks
Likes to spin, go on rides, swing, etc. - anything with motion

Start of program4 weeks8 weeks12 weeks
Touches things compulsively

Start of program4 weeks8 weeks12 weeks
A girl interested in makeup or jewelry

Start of program4 weeks8 weeks12 weeks
Does not like the feel of clothing on arms or legs; pulls clothes off

Start of program4 weeks8 weeks12 weeks
Doesn't like being touched and doesn't like to touch things

Start of program4 weeks8 weeks12 weeks
Incessantly smells everything

Start of program4 weeks8 weeks12 weeks
Prefers bland foods

Start of program4 weeks8 weeks12 weeks
Does not notice strong smells, such as burning wood, popcorn, or cookies baking in the oven

Start of program4 weeks8 weeks12 weeks
Avoid foods because of the way it looks

Start of program4 weeks8 weeks12 weeks
Hates having to eat and is not even interested in sweets

Start of program4 weeks8 weeks12 weeks
Extremely picky eater

Start of program4 weeks8 weeks12 weeks
TOTAL:
Sensory characteristics of a left brain delay
Doesn't seem to have many sensory issues or problems, such as a sensitivity to sound

Start of program4 weeks8 weeks12 weeks
Has good spatial awareness

Start of program4 weeks8 weeks12 weeks
Has good sense of balance

Start of program4 weeks8 weeks12 weeks
Eats just about anything

Start of program4 weeks8 weeks12 weeks
Has a normal to above-average sense of taste and smell

Start of program4 weeks8 weeks12 weeks
Likes to be hugged and held

Start of program4 weeks8 weeks12 weeks
Does not have an oddities concerning clothing

Start of program4 weeks8 weeks12 weeks
Has auditory processing problems

Start of program4 weeks8 weeks12 weeks
Seems to not hear well, although hearing tests are normal

Start of program4 weeks8 weeks12 weeks
Delay in speaking was attributed to ear infections

Start of program4 weeks8 weeks12 weeks
Gets motion sick and has other motion sickness issues

Start of program4 weeks8 weeks12 weeks
Is not undersensitive or oversensitive to pain

Start of program4 weeks8 weeks12 weeks
TOTAL:
Emotional characteristics of a right brain deficiency
Spontaneously cries and/or laughs and has sudden outbursts of anger or fear

Start of program4 weeks8 weeks12 weeks
Worries a lot and has several phobias

Start of program4 weeks8 weeks12 weeks
Holds onto past "hurts"

Start of program4 weeks8 weeks12 weeks
Has sudden emotional outbursts that appear overreactive and inappropriate to the situation

Start of program4 weeks8 weeks12 weeks
Experiences panic and/or anxiety attacks

Start of program4 weeks8 weeks12 weeks
Sometimes displays dark or violent thoughts

Start of program4 weeks8 weeks12 weeks
Face lacks expression; doesn't exhibit much body language

Start of program4 weeks8 weeks12 weeks
Too uptight; cannot seem to loosen up

Start of program4 weeks8 weeks12 weeks
Lacks empathy and feelings for others

Start of program4 weeks8 weeks12 weeks
Lacks emotional reciprocity

Start of program4 weeks8 weeks12 weeks
Often seems fearless and is a risk taker

Start of program4 weeks8 weeks12 weeks
TOTAL:
Emotional characteristics of a left brain deficiency
Overly happy and affectionate; loves to hug and kiss

Start of program4 weeks8 weeks12 weeks
Frequently moody and irritable

Start of program4 weeks8 weeks12 weeks
Loves doing new or different things but gets bored easily

Start of program4 weeks8 weeks12 weeks
Lacks motivation

Start of program4 weeks8 weeks12 weeks
Withdrawn and shy

Start of program4 weeks8 weeks12 weeks
Excessively cautious, pessimistic, or negative

Start of program4 weeks8 weeks12 weeks
Doesn't seem to get any pleasure out of life

Start of program4 weeks8 weeks12 weeks
Socially withdrawn

Start of program4 weeks8 weeks12 weeks
Cries easily; feelings get hurt easily

Start of program4 weeks8 weeks12 weeks
Seems to be in touch with own feelings; reads people's emotions well

Start of program4 weeks8 weeks12 weeks
Gets embarrassed easily

Start of program4 weeks8 weeks12 weeks
Very sensitive to what others think about him or her

Start of program4 weeks8 weeks12 weeks
TOTAL:
Behavioral characteristics of a right brain delay
Logical thinker

Start of program4 weeks8 weeks12 weeks
Often misses the gist of a story

Start of program4 weeks8 weeks12 weeks
Always the last to get a joke

Start of program4 weeks8 weeks12 weeks
Gets stuck in set behavior; can't let it go

Start of program4 weeks8 weeks12 weeks
Lacks social tact and/or is antisocial and/or socially isolated

Start of program4 weeks8 weeks12 weeks
Poor time management; is always late

Start of program4 weeks8 weeks12 weeks
Disorganized

Start of program4 weeks8 weeks12 weeks
Has a problem paying attention

Start of program4 weeks8 weeks12 weeks
Is hyperactive and/or impulsive

Start of program4 weeks8 weeks12 weeks
Has obsessive thoughts or behaviors

Start of program4 weeks8 weeks12 weeks
Argues all the time and is generally uncooperative

Start of program4 weeks8 weeks12 weeks
Exhibits signs of an eating disorder

Start of program4 weeks8 weeks12 weeks
Failed to thrive as an infant

Start of program4 weeks8 weeks12 weeks
Mimics sounds or words repeatedly without really understanding the meaning

Start of program4 weeks8 weeks12 weeks
Appears bored, aloof, and abrupt

Start of program4 weeks8 weeks12 weeks
Considered strange by other children

Start of program4 weeks8 weeks12 weeks
Inability to form friendships

Start of program4 weeks8 weeks12 weeks
Has difficulty sharing enjoyment, interests, or achievements with other people

Start of program4 weeks8 weeks12 weeks
Inappropriately giddy or silly

Start of program4 weeks8 weeks12 weeks
Acts inappropriately in social situations

Start of program4 weeks8 weeks12 weeks
Talks incessantly and asks the same question repetitively

Start of program4 weeks8 weeks12 weeks
Has no or little joint attention, such as the need to point to an object to get your attention

Start of program4 weeks8 weeks12 weeks
Didn't look at self in mirror as toddler

Start of program4 weeks8 weeks12 weeks
TOTAL:
Behavioral characteristics of a left brain delay
Procrastinates

Start of program4 weeks8 weeks12 weeks
Is extremely shy, especially around strangers

Start of program4 weeks8 weeks12 weeks
Is very good at nonverbal communication

Start of program4 weeks8 weeks12 weeks
Is well liked by other children and teachers

Start of program4 weeks8 weeks12 weeks
Does not have any behavioral problems in school

Start of program4 weeks8 weeks12 weeks
Understands social rules

Start of program4 weeks8 weeks12 weeks
Has poor self-esteem

Start of program4 weeks8 weeks12 weeks
Hates doing homework

Start of program4 weeks8 weeks12 weeks
Is very good at social interaction

Start of program4 weeks8 weeks12 weeks
Makes good eye contact

Start of program4 weeks8 weeks12 weeks
Likes to be around people and enjoys social activities, such as going to parties

Start of program4 weeks8 weeks12 weeks
Doesn't like to go to sleepovers

Start of program4 weeks8 weeks12 weeks
Is not good at following routines

Start of program4 weeks8 weeks12 weeks
Can't follow multiple-step directions

Start of program4 weeks8 weeks12 weeks
Is in touch with own feelings

Start of program4 weeks8 weeks12 weeks
Jumps to conclusions

Start of program4 weeks8 weeks12 weeks
TOTAL:
Behavioral characteristics of a right brain delay
Poor math reasoning (word problems, geometry, algebra)

Start of program4 weeks8 weeks12 weeks
Poor reading comprehension and pragmatic skills

Start of program4 weeks8 weeks12 weeks
Misses the big picture

Start of program4 weeks8 weeks12 weeks
Very analytical

Start of program4 weeks8 weeks12 weeks
Likes "slapstick" or obvious physical humor

Start of program4 weeks8 weeks12 weeks
Is very good at finding mistakes (spelling)

Start of program4 weeks8 weeks12 weeks
Takes everything literally

Start of program4 weeks8 weeks12 weeks
Doesn't always reach a conclusion when speaking

Start of program4 weeks8 weeks12 weeks
Started speaking early

Start of program4 weeks8 weeks12 weeks
Has tested for a high IQ, but scores in the whole spectrum; or IQ is above normal in verbal ability and below average in performance abilities

Start of program4 weeks8 weeks12 weeks
Was an early word reader

Start of program4 weeks8 weeks12 weeks
Is interested in unusual topics

Start of program4 weeks8 weeks12 weeks
Learns in a rote "memorizing" manner

Start of program4 weeks8 weeks12 weeks
Learns extraordinary amounts of specific facts about a subject

Start of program4 weeks8 weeks12 weeks
Is impatient

Start of program4 weeks8 weeks12 weeks
Speaks in a monotone; has little voice inflection

Start of program4 weeks8 weeks12 weeks
Is a poor nonverbal communicator

Start of program4 weeks8 weeks12 weeks
Doesn't like loud noises (like fireworks)

Start of program4 weeks8 weeks12 weeks
Speaks out loud regarding what he or she is thinking

Start of program4 weeks8 weeks12 weeks
Talks "in your face" - is a space invader

Start of program4 weeks8 weeks12 weeks
Good reader but does not enjoy reading

Start of program4 weeks8 weeks12 weeks
Analytical; led by logic

Start of program4 weeks8 weeks12 weeks
Follows rules without questioning them

Start of program4 weeks8 weeks12 weeks
Good at keeping track of time

Start of program4 weeks8 weeks12 weeks
Easily memorizes spelling and mathematical formulas

Start of program4 weeks8 weeks12 weeks
Enjoys observing rather than participating

Start of program4 weeks8 weeks12 weeks
Would rather read an instruction manual before trying something new

Start of program4 weeks8 weeks12 weeks
Math was often the first academic subject that became a problem

Start of program4 weeks8 weeks12 weeks
TOTAL:
Academic characteristics of a left brain delay
Very good at big picture skills

Start of program4 weeks8 weeks12 weeks
Is an intuitive thinker and is led by feelings

Start of program4 weeks8 weeks12 weeks
Good at abstract "free" association

Start of program4 weeks8 weeks12 weeks
Poor analytical skills

Start of program4 weeks8 weeks12 weeks
Very visual; loves images and patterns

Start of program4 weeks8 weeks12 weeks
Constantly questions why you're doing something or why rules exist

Start of program4 weeks8 weeks12 weeks
Has poor sense of time

Start of program4 weeks8 weeks12 weeks
Enjoys touching and feeling actual objects

Start of program4 weeks8 weeks12 weeks
Has trouble prioritizing

Start of program4 weeks8 weeks12 weeks
Is unlikely to read instructions before trying something new

Start of program4 weeks8 weeks12 weeks
Is naturally creative, but needs to work hard to develop full potential

Start of program4 weeks8 weeks12 weeks
Would rather do things instead of observe

Start of program4 weeks8 weeks12 weeks
Uses good voice inflection when speaking

Start of program4 weeks8 weeks12 weeks
Misreads or omits common small words

Start of program4 weeks8 weeks12 weeks
Has difficulty saying long words

Start of program4 weeks8 weeks12 weeks
Reads very slowly and laboriously

Start of program4 weeks8 weeks12 weeks
Had difficulty naming colors, objects, and letters as a toddler

Start of program4 weeks8 weeks12 weeks
Needs to hear or see concepts many times in order to learn them

Start of program4 weeks8 weeks12 weeks
Has shown a downward trend in achievement test scores or school performance

Start of program4 weeks8 weeks12 weeks
Schoolwork is inconsistent

Start of program4 weeks8 weeks12 weeks
Was a late talker

Start of program4 weeks8 weeks12 weeks
Has difficulty pronouncing words (poor with phonics)

Start of program4 weeks8 weeks12 weeks
Had difficulty learning the alphabet, nursery rhymes, or songs when young

Start of program4 weeks8 weeks12 weeks
Has difficulty finishing homework or finishing a conversation

Start of program4 weeks8 weeks12 weeks
Acts before thinking and makes careless mistakes

Start of program4 weeks8 weeks12 weeks
Daydreams a lot

Start of program4 weeks8 weeks12 weeks
Has difficulty sequencing events in the proper order

Start of program4 weeks8 weeks12 weeks
Often writes letters backwards

Start of program4 weeks8 weeks12 weeks
Is poor at basic math skills

Start of program4 weeks8 weeks12 weeks
Has poor memorization skills

Start of program4 weeks8 weeks12 weeks
Has poor academic ability

Start of program4 weeks8 weeks12 weeks
Has an IQ lower than expected and verbal scores are lower than nonverbal scores

Start of program4 weeks8 weeks12 weeks
Performs poorly on verbal tests

Start of program4 weeks8 weeks12 weeks
Needs to be told to do something several times before acting on it

Start of program4 weeks8 weeks12 weeks
Stutters or stuttered when younger

Start of program4 weeks8 weeks12 weeks
Is a poor speller

Start of program4 weeks8 weeks12 weeks
Doesn't read directions well

Start of program4 weeks8 weeks12 weeks
TOTAL:
Common immune characteristics of a right brain delay
Has lots of allergies

Start of program4 weeks8 weeks12 weeks
Rarely gets colds and infections

Start of program4 weeks8 weeks12 weeks
Has had eczema or asthma

Start of program4 weeks8 weeks12 weeks
Skin has little white bumps, especially on the back of the arms

Start of program4 weeks8 weeks12 weeks
Displays erratic behavior - good one day, bad the next

Start of program4 weeks8 weeks12 weeks
Craves certain foods, especially dairy and wheat products

Start of program4 weeks8 weeks12 weeks
TOTAL:
Common immune characteristics of a left brain delay
Gets chronic ear infections

Start of program4 weeks8 weeks12 weeks
Prone to benign tumors or cysts

Start of program4 weeks8 weeks12 weeks
Has taken antibiotics more than 10-15 times before the age of 10

Start of program4 weeks8 weeks12 weeks
Has had tubes put in the ears

Start of program4 weeks8 weeks12 weeks
Catches colds frequently

Start of program4 weeks8 weeks12 weeks
No allergies

Start of program4 weeks8 weeks12 weeks
TOTAL:
Autonomic characteristics of a right brain delay
Problems with bowels, such as constipation and diarrhea

Start of program4 weeks8 weeks12 weeks
Has a rapid heart rate and/or high blood pressure for age

Start of program4 weeks8 weeks12 weeks
Appears bloated, especially after meals, and often complains of stomach pains

Start of program4 weeks8 weeks12 weeks
Has body odor

Start of program4 weeks8 weeks12 weeks
Sweats a lot

Start of program4 weeks8 weeks12 weeks
Hands are always moist and clammy

Start of program4 weeks8 weeks12 weeks
TOTAL:
Autonomic characteristics of a left brain delay
Has a bedwetting problem

Start of program4 weeks8 weeks12 weeks
Has or had an irregular heartbeat, such as an arrhythmia or a heart murmur

Start of program4 weeks8 weeks12 weeks
TOTAL:
Taking the Total
Start of program 4 weeks 8 weeks 12 weeks
Right brain total:
Left brain total:
Grand total:
Hemisphericity (side of weakness)

LLLLRRRR
Motor characteristics of a right brain delay
Sensory characteristics of a right brain delay
Emotional characteristics of a right brain deficiency
Behavioral characteristics of a right brain delay
Academic characteristics of a right brain delay
Common immune characteristics of a right brain delay
Autoimmune characteristics of a right brain delay
Motor characteristics of a left brain delay
Sensory characteristics of a left brain delay
Emotional characteristics of a left brain deficiency
Behavioral characteristics of a left brain delay
Academic characteristics of a left brain delay
Common immune characteristics of a left brain delay
Autonomic characteristics of a left brain delay
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