Tracking Your Shifts for Children
Please rate items from a scale of 1 (no problem) to 10 (severe difficulties). 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
-
Day
Year
Date
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Child's Name:
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First Name
Last Name
Child's Birthdate:
*
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Month
-
Day
Year
Date
Your Name:
*
First Name
Last Name
Relationship to Child:
*
Email:
*
example@example.com
How many sessions has your child had?
*
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Sleep
Procrastination at bedtime
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1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Difficulty falling asleep
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Getting out of bed several times during the evening
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1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Bed wetting
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Staying asleep throughout the night
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Bad dreams
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1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Getting up in the morning
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1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Dressing and showering
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1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
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Observations at Home
Response to challenges/irritabilities
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1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Understanding what is said
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Making eye contact
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Obeying
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Correct assessment of social cues
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Anger outbursts
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Fear
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Continuous talking/monologue
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Fluid conversation
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1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Maintaining continuous attention
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Hyperactivity
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Disruptive behavior while eating
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Reckless endangerment
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Can stop activities (switch)
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Cleaning up
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Playing with other children
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Trouble with changes
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Obsessions/acts/tics
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Sense of time
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Allergies
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Tantrums/meltdowns
*
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
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Observations at School
Please fill out the questions about school as appropriate. Each item is scored between 1 = no problem and 10 = severe difficulties, and scores are measured as an average over the past week.
Being ready in time for school
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Bag: homework and books in order
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Concentration: easily distracted
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Concentration: dreaming
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Reading
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Disruptive behavior
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Bullying other children
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Being bullied
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Reprimanded or sent out of the classroom
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Starting homework
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Finishing homework
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Nervousness/fearfulness
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
Extreme shyness
1
2
3
4
5
6
7
8
9
10
No Problem
Severe Difficulties
1 is No Problem, 10 is Severe Difficulties
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Additional concerns to be tracked (optional):
Please rate each additional item from 1-10 with 1 being no problem and 10 being severe difficulties
Questions, comments or observations (optional):
Submit
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