KC Neurofeedback Questionnaire
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KANSAS CITY NEUROFEEDBACK Central Nervous System Questionnaire Name ________________________________________ Date of Birth _______________ Age ____________ Today’s Date _______________ Time ____________ Diagnosis _____________________________________ Are you able to drive a motor vehicle? _______ Yes _______ Partially ________ No Are you able to work or study? _______ Yes _______ Partially ________ No Are you able to sustain a close relationship with someone? _______Yes _______Partially _______No In general, how frequently have you had problems in the following area? Please pick a number from 0-to-10, “0” means Not at all and “10” means All the time. If one or more of your parents had this or a similar problem place a “P” in the column headed by “Parents”. If the problem came on suddenly, put an “S” in the column headed by “Suddenly”. Sensory Light, in general, bothers you Problems with the sense of smell Problems with vision Problems with hearing Problems with the sense of touch Frequency (0-10) Parents Suddenly _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ ______ ______ ______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Emotions Problems with sudden, unexplained changes in mood Problems with sudden, unexplained fearfulness Problems with unexplained spells of depression Problems with explosiveness Problems with irritability Problems with suicidal thoughts or actions Persistent phobias Shyness Anxiety Feelings of panic _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Emotions (con’t) Cannot feel or express emotions Periods of rage Dark or violent thoughts Problems controlling aggression Accelerates an argument Difficulty getting along with others Poor self esteem Clarity Feel “foggy” and have problems with clarity Problems following conversations (with good hearing) Problems with confusion Problems following what you are reading Realize you have no idea what you have been reading Problems with concentration Problems with attention Problems with sequencing Problems with prioritizing Problems not finishing what you start Problems organizing your room, office, paperwork Problem with getting lost in daydreaming You cover up that you don’t know what was said or asked of you Low motivation Periods of spaciness or confusion Poor time management Short attention span Energy Problems with stamina Fatigue during the day Trouble sleeping at night Problem awakening at night Problems falling asleep again Tire easily Hyperactivity Memory Forget what you have just heard Forget what you are doing, what you need to do Problems with procrastination and lack of initiative Problems not learning from experience Difficulty with word finding Difficulty with short term memory Difficulty with long term memory Frequency (0-10) Parents _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Frequency (0-10) Parents Suddenly _______ _______ _______ _______ _______ _______ _______ Suddenly _______ _______ _______ ______ ______ ______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Frequency (0-10) Parents _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Frequency (0-10) Parents _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Suddenly _______ _______ _______ _______ _______ _______ _______ Suddenly _______ _______ _______ _______ _______ _______ _______ Movement Problems with paralysis of one or more limbs Problems focusing or converging the eyes Tics Tremors Difficulty with fine motor control Poor handwriting Use of left leg or foot Use of right leg or foot Use of left arm or hand Use of right arm or hand Difficulty with balance Difficulty with walking Pain Frequency (0-10) Parents _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Frequency (0-10) Parents Suddenly _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Suddenly Head pain that is steady _______ _______ _______ Head pain that is throbbing _______ _______ _______ Shoulder and neck pain _______ _______ _______ Wrist pain _______ _______ _______ Knee pain _______ _______ _______ Over-all pain _______ _______ _______ Joint pain _______ _______ _______ Other pain (specify) __________________________________________________________________ Other Problems Seizures Problems with nausea Problems with speech or articulation Dizziness \ Noise in ears (Tinnitus) Nausea Cold hands Quick startle reaction Chronic lateness Procrastination Reading difficulty Difficulty with math Difficulty with logic Difficulty with problem solving Difficulty with planning ahead Do not learn from experience Frequency (0-10) Parents _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Additional Problems Please specify any other problems or behaviors that are of concern to you. _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Suddenly _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ 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