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Patient:________________________________________________
Date:___________________
Please rate the following
symptoms from 1 for seldom to 5 very often:
Sleep
|
Difficulty falling
sleep
|
|
Difficulty Maintaining
Sleep
|
|
|
Difficulty Waking
|
|
Nightmares or Vivid Dreams
|
|
|
Night terrors
|
|
Restless Sleep
|
|
|
Snoring
|
|
Sleep Apnea
|
|
|
Bruxism
|
|
Sleep Walking
|
|
|
Talking during sleep
|
|
Night sweats
|
|
|
Narcolepsy
|
|
Restless Leg
|
|
|
Periodic leg Movements
|
|
Nocturnal enuresis
|
|
Attention and Concentration
|
Poor short-term memory
|
|
Distractibility
|
|
|
Unmotivated
|
|
Difficulty completing
tasks
|
|
|
Difficulty thinking
clearly
|
|
Difficulty making
decisions
|
|
|
Poor vocabulary
|
|
Messy handwriting
|
|
|
Poor drawing ability
|
|
Poor math
|
|
|
Reading difficulty
|
|
Not listening
|
|
|
Lacking common sense
|
|
Slow thinking
|
|
|
Lack of alertness
|
|
Difficulty shifting
tasks
|
|
|
Poor concentration
|
|
Poor sustained
attention
|
|
|
Difficulty shifting
attention
|
|
Difficulty
understanding conversations
|
|
|
Difficulty organizing
time or space
|
|
Poor word finding
|
|
|
Difficulty remembering
names
|
|
Poor verbal expression
|
|
|
Difficulty following
directions
|
|
|
|
Sensory
|
Visual hypersensitivity
|
|
Auditory
hypersensitivity
|
|
|
Tactile
hypersensitivity
|
|
Tinnitus
|
|
|
Vertigo
|
|
Visual deficits
|
|
|
Chemical sensitivities
|
|
Somatosensory deficits
|
|
|
Poor body awareness
|
|
Motion sickness
|
|
Behavioral
|
Stuttering
|
|
Poor speech
articulation
|
|
|
Impulsivity
|
|
Rages
|
|
|
Hyperactivity
|
|
Class clown
|
|
|
Motor or vocal tics
|
|
Compulsive behaviors
|
|
|
Inflexibility
|
|
Manipulative behaviors
|
|
|
Aggressive behaviors
|
|
Oppositional or defiant
behavior
|
|
|
Crying
|
|
Poor eye contact
|
|
|
Autistic stimming
|
|
Addictive behaviors
|
|
|
Nail biting
|
|
Lack of social interest
|
|
|
Lack of appetite
awareness
|
|
Compulsive eating
|
|
|
Binging and purging
|
|
Lack of sense of humor
|
|
|
Poor grooming
|
|
Excessive talking
|
|
|
Poor social or
emotional reciprocity
|
|
Anorexia
|
|
|
Self-injurious behavior
|
|
|
|
Emotional
|
Irritability
|
|
Agitation
|
|
|
Emotional Reactivity
|
|
Mood swings
|
|
|
Depression
|
|
Mania
|
|
|
Anxiety
|
|
Fears
|
|
|
Obsessive worries
|
|
Lack of emotional
awareness
|
|
|
Lack of social awareness
|
|
Low self-esteem
|
|
|
Panic attacks
|
|
Flashbacks of trauma
|
|
|
Dissociative episodes
|
|
Anger
|
|
|
Impatience
|
|
Suicidal thoughts
|
|
|
Paranoia
|
|
Feelings of unreality
|
|
|
Lack of pleasure
|
|
Difficult to soothe
|
|
|
Obsessive negative
thoughts
|
|
Easily embarrassed
|
|
Physical
|
Low muscle tone
|
|
Spasticity
|
|
|
Chronic constipation
|
|
Irritable bowel
|
|
|
Seizures
|
|
Poor fine motor
coordination
|
|
|
Poor gross motor
coordination
|
|
Poor balance
|
|
|
Immune deficiency
|
|
PMS symptoms
|
|
|
Heart palpitations
|
|
Tachicardia
|
|
|
High blood pressure
|
|
Reflux
|
|
|
Tremor
|
|
Rigidity
|
|
|
Fatigue
|
|
Asthma
|
|
|
Sugar craving and
reactivity
|
|
Allergies
|
|
|
Muscle tension
|
|
Hot flashes
|
|
|
Sweating
|
|
Muscle weakness
|
|
|
Stress incontinence
|
|
Urge incontinence
|
|
|
Encopresis
|
|
Nausea
|
|
|
Difficulty walking or
moving
|
|
Effort fatigue
|
|
|
Difficulty working
|
|
Clumsiness
|
|
|
Muscle twitches
|
|
Skin rashes
|
|
Pain
|
Chronic aching pain
|
|
Migraine headaches
|
|
|
Muscle tension
headaches
|
|
Trigeminal neuralgia
|
|
|
Sciatica
|
|
Fibromyalgia pain
|
|
|
Chronic nerve pain
|
|
Stomach aches
|
|
|
Joint pain
|
|
Muscle pain
|
|
|
Jaw pain
|
|
Abdominal pain
|
|
|
Sinus headaches
|
|
|
|
|
