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Checklist of Concerns
Progress check before/during/after neurofeedback sessions
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English (US)
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1
Client/patient name
*
This field is required.
First Name
Last Name
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2
Phone Number
*
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Area Code
Phone Number
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3
Email
*
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example@example.com
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4
Is this your first session?
YES
NO
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5
If no, where else and when did you receive the same services last?
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6
Chief complaint (s):
*
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Main reason(s) for requesting services
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7
Allergies
*
This field is required.
1=no problem, 10=severe
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8
Asthma
*
This field is required.
1=no problem, 10=severe
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9
Frequent colds
*
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1=no problem, 10=severe
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10
Details of Immunity problems (if any):
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11
Take a long time to fall asleep
*
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1=no problem, 10=severe
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12
Wake up at night/can't fall asleep
*
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1=no problem, 10=severe
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13
Wake up too early (when there's no need to)
*
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1=no problem, 10=severe
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14
Feel tired when wake up/don't feel rested
*
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1=no problem, 10=severe
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15
Nightmares
*
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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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18
Shortness of breath/shallow breathing/holding breath
*
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1=no problem, 10=severe
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19
Dizziness
*
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1=no problem, 10=severe
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20
Details of lungs/breathing problems (if any):
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Ok
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21
Bloating or gas
*
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1=no problem, 10=severe
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22
Irritable bowel
*
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1=no problem, 10=severe
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23
Constipation
*
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1=no problem, 10=severe
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24
Diarrhea
*
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1=no problem, 10=severe
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25
Details of intestines/abdominal problems (if any):
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26
Thyroid problems
*
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1=no problem, 10=severe
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27
PMS symptoms
1=no problem, 10=severe, or n/a
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28
Hot flashes
1=no problem, 10=severe, or n/a
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29
Details of hormone problems (if any):
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30
Pain in muscles/joints
*
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1=no problem, 10=severe
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31
Fibromyalgia
*
This field is required.
1=no problem, 10=severe
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32
Bodily fatigue
*
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1=no problem, 10=severe
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33
Details of muscle problems (if any):
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Ok
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34
Headaches
*
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1=no problem, 10=severe
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35
Migraines
*
This field is required.
1=no problem, 10=severe
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36
Seizures
*
This field is required.
1=no problem, 10=severe
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37
Short term memory loss
*
This field is required.
1=no problem, 10=severe
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38
Long term memory loss
*
This field is required.
1=no problem, 10=severe
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39
Blocked on words
*
This field is required.
1=no problem, 10=severe
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40
Body or vocal tics
*
This field is required.
1=no problem, 10=severe
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41
Details of nervous system problems (if any):
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Ok
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42
Difficulty concentrating/easily distracted
*
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1=no problem, 10=severe
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43
Difficulty organizing and/or scheduling
*
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1=no problem, 10=severe
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44
Difficulty prioritizing tasks
*
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1=no problem, 10=severe
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45
Losing train of thought
*
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1=no problem, 10=severe
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46
Hyperactive/can't sit still
*
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1=no problem, 10=severe
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47
Details of attention/organization problems (if any):
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48
Verbally impulsive
*
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1=no problem, 10=severe
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49
Inverting numbers/letters
*
This field is required.
1=no problem, 10=severe
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50
Dyslexia
*
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1=no problem, 10=severe
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51
Details of learning problems (if any):
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Ok
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52
Drink alcohol
*
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1=no problem, 10=severe
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53
Smoke marijuana
*
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1=no problem, 10=severe
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54
Smoke cigarettes
*
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1=no problem, 10=severe
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55
Binge eat
*
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1=no problem, 10=severe
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56
Eat sweets/carbohydrates
*
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1=no problem, 10=severe
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57
Don't eat enough
*
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1=no problem, 10=severe
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58
Drink caffeinated or energy drinks
*
This field is required.
1=no problem, 10=severe
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59
Overspend
*
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1=no problem, 10=severe
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60
Details of habits (if any):
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Ok
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61
Mood swings
*
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1=no problem, 10=severe
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62
Feel depressed or down
*
This field is required.
1=no problem, 10=severe
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63
Feel worried
*
This field is required.
1=no problem, 10=severe
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64
Feel like the world isn't a safe place
*
This field is required.
1=no problem, 10=severe
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65
Feel like others are against me
*
This field is required.
1=no problem, 10=severe
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66
Feel anxious
*
This field is required.
1=no problem, 10=severe
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67
Panic attacks
*
This field is required.
1=no problem, 10=severe
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68
Feel hopeless
*
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1=no problem, 10=severe
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69
Feel numb
*
This field is required.
1=no problem, 10=severe
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70
Have repetitive negative thoughts/worries that don't stop
*
This field is required.
1=no problem, 10=severe
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71
Need to repeat actions over and over
*
This field is required.
1=no problem, 10=severe
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72
Phobias
*
This field is required.
1=no problem, 10=severe
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73
Feel angry/angry outbursts
*
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1=no problem, 10=severe
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74
Feel overwhelmed
*
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1=no problem, 10=severe
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75
Details of emotions (if any):
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Ok
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76
Any other issues not mentioned above (if any):
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77
Medications:
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Ok
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78
Head Traumas/Loss of Consciousness:
Include when/how long ago and how often
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79
How did you hear about Beaverton Neurofeedback (or neurofeedback in general)?
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