Symptom Inventory: (name)
(date)
(total score)
Rating Scale: 0=no symptoms; 1=occasionally experienced; 2=often experienced; 3=almost always experienced
Please rate these symptoms based on your experiences & observations over this past month.
_ Extremely sensitive to sound
Sleep___________ _ Extremely sensitive to touch
_ Difficulty falling asleep
_ Tinnitus (ringing in ear)
_ Difficulty maintaining sleep
_ Vertigo (dizziness)
_ Difficulty waking
_ Seriously impaired vision
_ Nightmares or vivid dreams
_ Chemical sensitivities
_ Night terrors
_ *Somato-sensory deficits
(developmental issue)
_ Restless sleep
_ Poor body awareness
_ Snoring
_ Motion sickness
_ *Sleep apnea
_ Tooth grinding during sleep (Bruxism) _ Clumsiness
_ Poor grooming
_ Sleep walking
_ Talking during sleep
Behavioral_______
_ Night sweats
_ Stuttering
_ *Narcolepsy (can’t stay awake _ Poor Speech articulation
during the day)
_ Impulsivity
_ Periodic leg movements
_ Rages
Attention and
_ Hyperactivity
learning_________
_ Class clown
_ Inattention
_ Motor or vocal tics
_ Poor short-term memory
_ Compulsive behaviors
_ Distractibility (trouble sitting still) _ Inflexibility
_ Doesn’t try very hard
_ Manipulative behavior
_ Trouble finishing things
_ Aggressive behavior
_ Difficulty thinking clearly
_ Oppositional and defiant
behavior
_ Difficulty making decisions
_ Crying
_ Poor vocabulary
_ Poor eye contact
_ Messy handwriting
_ Autistic self stimulation
_ Poor drawing ability
_ Addictive behaviors
_ Poor math
_ Nail biting
_ Reading difficulty
_ Lack of social interest
_ Not listening
_ Lack of appetite awareness
_ Lacking common sense
_ Compulsive eating
Sensory_________
_ Binging and purging
_ Extremely sensitive to light
_ Lack of sense of humor
Emotional________ _
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Irritability (snappy)
Agitation (can’t settle down)
Emotional reactivity-easily upset
Mood swings
Depression
Mania
Anxiety
Fears
Obsessive worries
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Tremor (periodic mild shaking)
Rigidity (always very stiff)
Fatigue
Asthma
Sugar craving and reactivity
Allergies
Hot flashes
Muscle tension
Bedwetting/incontinence
Pain______________
_ Chronic aching pain
Lack of social awareness
_ Migraine headaches
Low self-esteem
_ Muscle tension headaches
Panic attacks
_ *Trigeminal neuralgia
Flashbacks of trauma
_ *Sciatica
Dissociative episodes
_ *Fibromyalgia pain
Anger
_ Chronic nerve pain
Impatience
_ Stomach aches
Suicidal thoughts
_ Intestinal pain
Paranoia
_ Joint pain
Physical__________ _ *Neuropathy pain
_ Low muscle tone
_ Muscle pain
_ *Spasticity
_ Jaw pain
Medications for:
_ Chronic constipation
(tracking dose or frequency of use)
_ *Irritable bowel
_ Attention/Hyperactivity
_ *Seizures (epilepsy)
__ Pain
_ Poor fine motor coordination _ Sleep
__ Constipation
_ Poor gross motor coordination _ Mood
_ Behavior
__Hormones
_ Poor balance
_ Allergies
_ *Immune deficiency
_ Asthma
_ PMS symptoms
_ Seizures
_ Heart palpitations
_ Inflammation
_ *Tachycardia
_ Movement disorders
_ *High blood pressure
_ Blood pressure
_ *Reflux
_ Blood sugar/Cholesterol
_ Reflux
Lack of emotional awareness
* = Medically diagnosed conditions