Tracking Your Shifts
Please rate items from a scale of 0 (no concern) to 10 (extreme concern). If you are unsure, use the past week as your guide. Any concerns mentioned are intended as examples only and not meant to suggest that NeurOptimal® treats, mitigates, cures, or diagnoses any listed concern. Identifying concerns is one of many ways to measure shifts in brain functioning and perception.
Today's Date:
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Month
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Name:
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First Name
Last Name
Birthdate:
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Month
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Day
Year
Date
Email:
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example@example.com
Occupation:
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Have you ever served in the military or as a first responder? If so, please specify in what capacity.
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How many sessions have you had?
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Itchy or irritated nose, sneezing
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Wheezing
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Catch cold too often
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Run down
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Tired
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Awake too long when you go to bed
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Waking up during the night
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Waking up before you want to
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficult to wake up in the morning
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Bad dreams
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficulty breathing at night
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Out of bed but not knowing how you got there
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Skin difficult to mangage
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Hair weaker or less lustrous than you'd like
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Nails weak, flaking or tearing
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Blurry vision at times
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Areas where you can't see anything
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Spots floating in front of you
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Difficult to hear
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Ringing in your ears
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Ears hurt inside
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Smells seem different or lost
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Nose gets blocked
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Grinding your teeth
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Things taste different
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Voice hoarse or sore
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Can't get enough air
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Heart too fast or jumpy
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Pulsing or throbbing in your head
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Heart skips a beat
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
World spinning around you
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Might throw up
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Tummy hurts
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Gassy, bloated
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Sensitive digestion
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Upset stomach
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficulty going to the bathroom
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Eat when not hungry, or feeling not hungry
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Trouble eating sweets
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Urges to eat sweet things
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Sensitive to heat or cold
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Slowed down or sped up
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Moody at certain times of the month
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Hot flashes
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Problems from being of a "certain age"
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Not interested in your partner
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Too interested in your partner or others
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Stiff and sore
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Areas that really hurt when touched
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Muscles hurt
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Fatigued
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Pains in your head
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Going to pass out
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Lose consciousness
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficult to remember things
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficult to find your words
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficulty reading
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficult to speak sometimes
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Shaky
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Weak
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Too active
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Can't balance on one leg
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Moving your head or saying words you don't intend
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Difficulty paying attention
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0
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Easily distracted
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Make a lot of mistakes
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Disorganized
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficult to complete tasks
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Lose your train of thought
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Difficult to complete studies or work
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Get into trouble at school or work
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Mix up letters or numbers sometimes
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficult to know how things fit together
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficulty with some subjects
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Need to go to the bathroom but hard to start
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0
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Lose control of your urine sometimes
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficult to control going to the toilet
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Stinging sensations when going to the bathroom
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Drink too much sometimes
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Smoke cigarettes
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0
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Concerns about eating
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Need caffeine to get going
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0
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Use marijuana
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0
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Habits that concern you
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0
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Moody
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0
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Feeling low or flat
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0
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9
10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Feeling sad
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0
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8
9
10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Concerned about things
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0
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9
10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Feel terrified sometimes
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0
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9
10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Can't stop thinking about things that concern you
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0
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9
10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Thoughts you'd like to stop but can't
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0
1
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Need to do things over and over
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0
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9
10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Eat more food than you can comfortably eat
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0
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9
10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Careful to never eat too much
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0
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Make yourself throw up
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0
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Difficult to do things you'd like to do
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0
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Feeling that others are against you
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Get into trouble for your behavior
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Feeling angry
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10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Feeling overwhelmed
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No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
Feeling agitated while driving
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0
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9
10
No Concern
Extreme Concern
0 is No Concern, 10 is Extreme Concern
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Additional concerns to be tracked (optional):
Please rate each additional item from 1-10 with 1 being a mild concern and 10 being an extreme concern.
Questions or comments (optional):
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