Name  
E-mail  
Phone No  

Please check the box that most closely describes the statement...
1. Difficulty to pay attention to details, makes careless mistakes.  
2. Trouble in sustaining attention for routine situations (homework, completing chores, coordinating more than one task.)  
3. Easily distracted.  
4. Forgetful.  
5. Poor planning skills.  
6. Unmotivated for detailed tasks, retreats from structured learning.  
7. Gets drowsy if doing one task consistently (driving, sitting and listening, etc.)  
8. Gets anxious enough to disrupt performance for tests.  
9. Irrational fear (driving, flying, etc.)  
10. Anxiety overcomes calm reflection when confronted.  
11. Tendency to get argumentative or oppositional.  
12. Irritability and rage issues.   
13. Fear of being judged.  
14. Trouble breathing.   
15. Lacks self-confidence.   
16. Craves foods that help relax stress.   
17. Craves foods that relate to curving depression (celebration, mood food, etc.)   
18. Craves drugs or alcohol for emotional reasons.  
19. Obsesses about food and situations involving eating.   
20. Eats from emotional needs.  
21. Cannot stop a habit of eating certain foods.  
22. Feelings of sadness.  
23. Has a memory of negative impact that cannot be resolved.   
24. Has past memory of fear that overwhelms present situational reasoning and coping skills.  
25. Low energy to invest in any activity.  
26. Sleep problems, too little or too much.  
27. Chronic low self esteem.   
28. Preoccupation with thoughts.  
29. Longer periods to deal with grief than usual.   
30. Sad thoughts distract from performance.   
31. Extreme headaches or abdominal pain from uncertain origin.  
32. Preoccupation with moral or religious ideas.   
33. Periods of sweating, hot or cold flashes.  
34. Out of control when things do not go your way.   
35. Paranoia – extremely suspicious of everyone.   
36. Restlessness.  
37. Muscle tension.   
38. Problems in worrying about work or school.  
39. Overstressed.  
40. Temper outbursts.  

 

 

 

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