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Checklist of Concerns
Progress check during/after neurofeedback
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English (US)
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1
Name
First Name
Last Name
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2
Phone Number
Area Code
Phone Number
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3
Email
example@example.com
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4
Number of neurofeedback sessions as of today:
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5
Allergies
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This field is required.
1=no problem, 10=severe
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6
Asthma
*
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1=no problem, 10=severe
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7
Nose or sinuses blocked
*
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1=no problem, 10=severe
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8
Frequent colds
*
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1=no problem, 10=severe
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9
Details of Immunity problems (if any):
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10
Can't fall asleep
*
This field is required.
1=no problem, 10=severe
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11
Wake up at night/can't fall asleep
*
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1=no problem, 10=severe
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12
Wake up too early (when there's no need to)
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1=no problem, 10=severe
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13
Feel tired when wake up/don't feel rested
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1=no problem, 10=severe
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14
Nightmares
*
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1=no problem, 10=severe
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15
Snoring
*
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1=no problem, 10=severe
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16
Wake up and immediately start worrying
*
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1=no problem, 10=severe
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17
Details of sleep problems (if any):
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Ok
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Ok
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18
Shortness of breath/shallow breathing
*
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1=no problem, 10=severe
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19
Holding breath
*
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1=no problem, 10=severe
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20
Dizziness
*
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1=no problem, 10=severe
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21
Details of lungs/breathing problems (if any):
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Ok
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22
Bloating or gas
*
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1=no problem, 10=severe
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23
Irritable bowel
*
This field is required.
1=no problem, 10=severe
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24
Constipation
*
This field is required.
1=no problem, 10=severe
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25
Diarrhea
*
This field is required.
1=no problem, 10=severe
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26
Details of intestines/abdominal problems (if any):
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Ok
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Ok
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27
Thyroid problems
*
This field is required.
1=no problem, 10=severe
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28
PMS symptoms
1=no problem, 10=severe, or n/a
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29
Hot flashes
1=no problem, 10=severe, or n/a
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30
Waking up at night hot
*
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1=no problem, 10=severe
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31
Details of hormone/blood problems (if any):
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Ok
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Ok
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32
Pain in muscles/joints
*
This field is required.
1=no problem, 10=severe
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33
Lower back pain
*
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1=no problem, 10=severe
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34
Fibromyalgia
*
This field is required.
1=no problem, 10=severe
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35
Bodily fatigue
*
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1=no problem, 10=severe
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36
Details of muscle problems (if any):
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Ok
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Ok
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37
Headaches
*
This field is required.
1=no problem, 10=severe
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38
Migraines
*
This field is required.
1=no problem, 10=severe
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39
Seizures
*
This field is required.
1=no problem, 10=severe
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40
Short term memory loss
*
This field is required.
1=no problem, 10=severe
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41
Long term memory loss
*
This field is required.
1=no problem, 10=severe
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42
Blocked on words
*
This field is required.
1=no problem, 10=severe
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43
Body or vocal tics
*
This field is required.
1=no problem, 10=severe
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44
Details of nervous system problems (if any):
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Ok
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Ok
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45
Difficulty concentrating
*
This field is required.
1=no problem, 10=severe
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46
Easily distracted when trying to focus
*
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1=no problem, 10=severe
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47
Difficulty organizing and/or schedule
*
This field is required.
1=no problem, 10=severe
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48
Difficulty prioritizing tasks
*
This field is required.
1=no problem, 10=severe
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49
Losing train of thought
*
This field is required.
1=no problem, 10=severe
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50
Hyperactive/can't sit still
*
This field is required.
1=no problem, 10=severe
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51
Details of attention/organization problems (if any):
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Ok
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Ok
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52
Verbally impulsive
*
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1=no problem, 10=severe
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53
Inverting numbers/letters
*
This field is required.
1=no problem, 10=severe
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54
Spacial problems (putting things together, building things)
*
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1=no problem, 10=severe
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55
Details of learning problems (if any):
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Ok
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Ok
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56
Dyslexia
*
This field is required.
1=no problem, 10=severe
Todo
In Progress
Done
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57
Drink alcohol
*
This field is required.
1=no problem, 10=severe
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58
Smoke marijuana
*
This field is required.
1=no problem, 10=severe
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59
Smoke cigarettes
*
This field is required.
1=no problem, 10=severe
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60
Binge eat
*
This field is required.
1=no problem, 10=severe
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61
Eat sweets/carbohydrates
*
This field is required.
1=no problem, 10=severe
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62
Don't eat enough
*
This field is required.
1=no problem, 10=severe
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63
Drink caffeinated or energy drinks
*
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1=no problem, 10=severe
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64
Overspend
*
This field is required.
1=no problem, 10=severe
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65
Details of habits (if any):
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Ok
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Ok
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66
Rapid mood swings
*
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1=no problem, 10=severe
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67
Feel depressed or down
*
This field is required.
1=no problem, 10=severe
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68
Feel worried
*
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1=no problem, 10=severe
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69
Feel like the world isn't a safe place
*
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1=no problem, 10=severe
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70
Feel like others are against me
*
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1=no problem, 10=severe
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71
Feel anxious
*
This field is required.
1=no problem, 10=severe
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72
Panic attacks
*
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1=no problem, 10=severe
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73
Feel hopeless
*
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1=no problem, 10=severe
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74
Feel numb
*
This field is required.
1=no problem, 10=severe
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75
Have repetitive negative thoughts/worries that don't stop
*
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1=no problem, 10=severe
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76
Obsessive thoughts
*
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1=no problem, 10=severe
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77
Need to repeat actions over and over
*
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1=no problem, 10=severe
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78
Phobias
*
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1=no problem, 10=severe
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79
Feel angry/angry outbursts
*
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1=no problem, 10=severe
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80
Feel overwhelmed
*
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1=no problem, 10=severe
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81
Details of emotions (if any):
Huge
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Ok
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Ok
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82
Medications (have there been changes in medications recently?):
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83
Our recovery and the road to wellness is not linear. Most of us need either on-going or "touch-up" sessions to maintain results and see additional progress. Are you interested in continuing working with neurofeedback either now or in the future?
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84
What additional changes have you noticed since starting neurOptimal® training not mentioned above?
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