Basal Ganglia Please rate yourself (or the person you are evaluating) on each of the symptoms listed below using the following scale. If possible, also have someone else rate you. This is done to obtain amore complete picture of the situation. 0=never, 1=rarely, 2=occasionally, 3=frequently, 4=very frequently First Name Last Name Feelings of nervousness or anxiety * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Symptoms of heightened muscle tension (Headaches, sore muscles, hand tremor) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Feeling keyed up or on edge * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Quick to startle * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to freeze in anxiety-provoking situations * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Excessive fear of being judged or scrutinized by others * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Conflict avoidance * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Lacking confidence * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Sensitive to criticism * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Biting fingernails, or picking skin * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Always watching for bad things to happen * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Excessive motivation * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tics * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Poor handwriting * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Thank you! Prefrontal Cortex Please rate yourself (or the person you are evaluating) on each of the symptoms listed below using the following scale. If possible, also have someone else rate you. This is done to obtain amore complete picture of the situation. 0=never, 1=rarely, 2=occasionally, 3=frequently, 4=very frequently First Name Last Name Inability to give close attention to details or avoid careless mistakes * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Trouble sustaining attention in routine situations (homework, chores, paperwork) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Trouble listening * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Inability to finish things, poor follow-through * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Poor organization of time or space * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Distractibility * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Poor planning skills * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Difficulty expressing feeling and emotions * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Difficulty expressing empathy for others * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Excessive daydreaming * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Boredom * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Conflict seeking * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Difficulty waiting turn * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Impulsivity (saying or doing things without thinking first) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Frequent traffic violations * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Thank you! Limbic System Please rate yourself (or the person you are evaluating) on each of the symptoms listed below using the following scale. If possible, also have someone else rate you. This is done to obtain amore complete picture of the situation. 0=never, 1=rarely, 2=occasionally, 3=frequently, 4=very frequently First Name Last Name Feelings of sadness * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Moodiness * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Low energy * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Excessive guilt * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Crying spells * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Lowered interest in things usually considered fun * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Low self-esteem * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Decreased interest in sex * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Negative sensitivity to smells/odors * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Forgetfulness * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Poor concentration * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently My feelings are often or easily hurt * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Feeling overwhelmed by the tasks of daily life * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Sensitive to criticism * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Lacking confidence in own abilities * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Thank you! Temporal Lobe Please rate yourself (or the person you are evaluating) on each of the symptoms listed below using the following scale. If possible, also have someone else rate you. This is done to obtain amore complete picture of the situation. 0=never, 1=rarely, 2=occasionally, 3=frequently, 4=very frequently First Name Last Name Short fuse, or periods of extreme irritability * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of rage with little provocation * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Frequent misinterpretation of comments as negative when they are not * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Irritability that tends to build, then explode, then recedes; often feel tired after rage * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of spaciness or confusion * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of panic and/or fear for no specific reason * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Visual or auditory changes, such as seeing shadows or hearing muffled sounds * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Frequent periods of deja vu, or jamais vu (not recalling a familiar place or person) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Sensitivity or mild paranoia * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Headaches or abdominal pain of uncertain origin * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Dark thought, such as suicidal or homicidal thoughts * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of forgetfulness * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Memory problems * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Reading comprehension problems * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Preoccupation with moral or religious ideas * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Thank you! Anterior Cingulate Gyrus Please rate yourself (or the person you are evaluating) on each of the symptoms listed below using the following scale. If possible, also have someone else rate you. This is done to obtain amore complete picture of the situation. 0=never, 1=rarely, 2=occasionally, 3=frequently, 4=very frequently First Name Last Name Excessive or senseless worrying * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Being upset when things do not go your way * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Being upset when things are out of place * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to be oppositional or argumentative * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to have repetitive negative thoughts * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency toward compulsive behaviors 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Intense dislike of change * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to hold grudges * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Trouble shifting attention from subject to subject * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Trouble shifting from task to task * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Difficulties seeing options in situations * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to hold on to own opinions and not listen to others * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Being very upset unless things are done a certain way * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Perception by others that you worry too much * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to say no without first thinking about question * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Unhealthy perfectionism * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Thank you! ANX/DEP QUESTIONAIRRE Please rate yourself (or the person you are evaluating) on each of the symptoms listed below using the following scale. If possible, also have someone else rate you. This is done to obtain amore complete picture of the situation. 0=never, 1=rarely, 2=occasionally, 3=frequently, 4=very frequently First Name Last Name Frequent feeling of nervousness or anxiety * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Panic attacks * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Avoidance of places because of fear of having an anxiety attack * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Symptoms of heightened muscle tension (headache, sore muscles, hand tremor) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of heart pounding, nausea or dizziness * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to predict the worst 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Multiple persistent fears or phobias (such as dying, doing something crazy) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Conflict avoidance * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Excessive fear of being judged or scrutinized by others * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Easily startled or tendency to freeze ni anxiety provoking or intense situations * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Seems shy, timid, and easily embarrassed * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Bites fingernails or picks skin * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Persistent sad, or "empty" mood * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Loss of interest or pleasure in activities that are usually fun, including sex * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Restlessness, irritability, or excessive crying * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Feelings of guilt, worthlessness, hopelessness, pessimism * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Sleeping too much or too little, early morning awakening * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Appetite and/or weight loss or overeating and weight gain * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Decreased energy, fatigue, feeling "slowed down" * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Thoughts of death or suicide, or suicide attempts * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Difficulty concentrating, remembering, or making decisions * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Persistent physical symptoms that do not respond ot treatment, such as headaches, digestive disorders, and chronic pain * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Persistent negativity or chronic low self-esteem * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Persistent feeling of being dissatisfied or bored * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Excessive or senseless worrying * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Upset when things are out of place or things don't go the way you planned * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to be oppositional or argumentative * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to have repetitive negative or anxious thoughts * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency toward compulsive behaviors * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Intense dislike for change * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to hold grudges * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Difficulties seeing options in situations * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tendency to hold onto own opinion and not listen to others * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Needing to have things done a certain way or you become very upset * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Others complain that you worry too much * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Tend to say no without first thinking about question * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of abnormally elevated, depressed, or anxious mood * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of decreased need for sleep, feel energetic on dramatically less sleep than usual * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of grandiose notions * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of increased talking or pressured speech * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of too many thoughts racing through the mind * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of markedly increased energy * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of poor judgement that leads ot risk-taking behavior (separate from usual behavior) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of inappropriate social behavior * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of irritability or aggression * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of delusional or psychotic thinking * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Short fuse or periods of extreme irritability * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of rage with little provocation * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Often misinterprets comments as negative when they are not * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of spaciness or confusion * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of panic and/or fear for no specific reason * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Visual or auditory changes, such as seeing shadows or hearing muffled sounds * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Frequent periods of deja vu (feeling of being somewhere you have never been) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Sensitivity or mild paranoia * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Headaches or abdominal pain of uncertain origin * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently History of head injury or family history of violence or explosiveness * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Dark thoughts, may involve suicidal or homicidal thoughts * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Periods of forgetfulness or memory problems * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Trouble staying focused * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Spaciness or feeling in a fog * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Overwhelmed by tasks of daily living * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Feels tired, sluggish, or slow moving * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Procrastination, failure to finish things * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Chronic boredom * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Loses things * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Easily distracted * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Forgetful * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Poor planning skills * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Difficulty expressing feelings * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Difficulty expressing empathy for others * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Thank you! ADD TYPE QUESTIONNAIRE Please rate yourself (or the person you are evaluating) on each of the symptoms listed below using the following scale. fI possible, also have someone else rate you. This is done to obtain a more complete picture of the situation. 0=never, 1=rarely, 2=occasionally, 3=frequently, 4=very frequently First Name Last Name 1. Easily distracted * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 2. Difficulty sustaining attention span for most tasks in play, school, or work * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 3. Trouble listening when others are talking * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 4. Trouble following through on tasks or instructions * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 5. Difficulty keeping an organized area (room, desk, book bag, filing cabinet, locker, etc.) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 6. Trouble with time, for example, frequently late or hurried, tasks take longer than expected, projects or homework are "last minute" or turned in late 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 7. Tendency to lose things * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 8. Makes careless mistakes, or poor attention to detail * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 9. Forgetful * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 10. Daydreams excessively * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 11. Complains of being bored * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 12. Appears apathetic or unmotivated * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 13. Tired, sluggish, or slow moving * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 14. Spacey or seems preoccupied * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 15. Restless or highly active * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 16. Trouble sitting still * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 17. Fidgety; in constant motion (hands, feet, body) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 18. Noisy; tough time being quiet * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 19. Act if "driven by a motor" * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 20. Talks excessively * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 21. Impulsive (does not think through comment or actions before said or done * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 22. Difficulty waiting turn * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 23. Interrupts or intrudes on others (butts into conversation or games) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 24. Worries excessively or senselessly * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 25. Super organized * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 26. Strong tendency to get locked into negative thoughts; has the same thought over and over * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 27. Oppositional, argumentative * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 28. Tendency towards compulsive behavior * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 29. Trouble shifting attention from subject to subject * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 30. Intense dislike for change * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 31. Tendency to hold grudges * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 32. Difficulties seeing options in situations * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 33. Tendency to hold onto own opinion and not listen to others * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 34. Tendency to get locked into a course of action, whether it is good for the person * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 35. Needs to have things done a certain way or becomes very upset * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 36. Others complain he/she worries to much * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 37. Periods of quick temper or rages with little provocation * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 38. Misinterprets comments as negative when they are not * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 39. Irritability tends to build, then explodes, then recedes; often tired after a rage * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 40. Periods of spaciness or confusion * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 41. Periods of panic and/or fear for no specific reason * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 42. Perceives visual changes, such as seeing shadows or objects changing shape * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 43. Frequent periods of Deja Vu * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 44. Sensitive or mildly paranoid * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 45. Headaches or abdominal pain of unknown origin * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 46. History of a head injury or a family history of violence or explosiveness * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 47. Dark thoughts, may involve suicidal or homicidal thoughts 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 48. Periods of forgetfulness or memory problems * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 49. Short fuse or periods of extreme irritability * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 50. Moody * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 51. Negative * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 52. Low energy * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 53. Frequently irritable * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 54. Tendency to be socially isolated * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 55. Frequent feelings of hopelessness * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 56. Lowered interest in things that are usually considered fun * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 57. Undergoes sleep changes (too much, too little) * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 58. Chronic low self esteem * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 59. Angry or aggressive * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 60. Sensitive to light, noise, or touch * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 61. Frequent or cyclical mood changes * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 62. Inflexible, rigid ni thinking * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 63. Demands to have his or her way, even when to no multiple times * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 64. Periods of mean, nasty, or insensitive behavior * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 65. Periods of increased talkativeness * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 66. Periods of increased impulsivity * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 67. Displays unpredictable behavior * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 68. Way of thinking is grandiose or 'larger than life' * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 69. Talks fast * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 70. Feels that thoughts go fast * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently 71. Appears anxious or fearful * 0 = Never 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Very Frequently Thank you! PATIENT HEALTH QUESTIONNAIRE (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? 0=not at all, 1=several days, 2=more than half the days, 3=nearly everyday, First Name Last Name Little interest or pleasure in doing things * 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly everyday Feeling down, depressed, or hopeless * 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly everyday Trouble falling or staying asleep, or sleeping too much * 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly everyday Feeling tired or having little energy * 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly everyday Poor appetite or overeating * 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly everyday Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly everyday Trouble concentrating on things, such as reading the newspaper or watching television * 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly everyday Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual * 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly everyday Thoughts that you would be better of dead or of hurting yourself in some way * 0 = Not at all 1 = Several days 2 = More than half the day 3 = Nearly everyday If you checked of any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? * 0 = Not difficult at all 1 = Somewhat difficult 2 = Very difficult 3 = Extreme difficult Thank you! 3A24-Brain Wellness Rank yourself in order beginning with 1, ending with 7 on each of the following symptoms in the individual columns, NO NUMBER WILL BE USED TWICE 1= Most common 7= Least common First Name Last Name Column 2 Over-focused, worrying, trouble letting go of hurts * 1 = Most common 6,7 = Least common Inatentive, impulsive, easily distracted * 1 = Most common 6,7 = Least common Combination of types 1 and 2 * 1 = Most common 6,7 = Least common Sad, or depressed mood, winter blues, carbohydrate cravings, los of interest, sleeps a lot, low energy, self medicate to improve moods * 1 = Most common 6,7 = Least common Anxious, tense, nervous, predicts the worst, self medicates to calm * 1 = Most common 6,7 = Least common Temper problems, mod instability, memory problems, learning disabilities * 1 = Most common 6,7 = Least common Column 3 Anxious, tense, nervous, predicts the worst, self medicates to calm * 1 = Most common 6,7 = Least common Depression, feeling hopeless, low energy, poor appetite, insomnia * 1 = Most common 6,7 = Least common Combination of types 1,and 2 * 1 = Most common 6,7 = Least common Over-focused, worrying, oppositional, holds grudges * 1 = Most common 6,7 = Least common Temper problems, mod instability, irritability, memory problems, learning disabilities * 1 = Most common 6,7 = Least common Sadness, anxiety, low energy, cognitive problems * 1 = Most common 6,7 = Least common Mood cycles (bipolar, cyclothimia, severe MPS * 1 = Most common 6,7 = Least common Thank you!
