http://www.mapleshores.ca/site/assets/files/1031/neurological_questionnaire.pdf
NEUROBEHAVIORAL SYMPTOM CHECKLIST
Patient Name:____________________________________________________ Date: ____________________
From time to time, everyone feels out of sorts, not themselves, nervous, depressed, irritable, or anxious. Illness and prescription medications can alter behavior, perception, and mood states as well. These questions are designed to assist you and your healthcare provider in identifying patterns of behavior and feelings that tend to affect the quality of your relationships with family and friends, performance at work, and your overall sense of well-being. By sharing this information, you participate as a partner in exploring some of the possible underlying causes of any emotional or mental discomfort you may be experiencing.
Directions:
Please check the boxes that best describe your feelings and ability to function most of the time. When answering each question, consider the degree to which your daily life is affected.
1. Over the last year, I have experienced:
Becoming forgetful
Lapses in memory
Becoming less attentive
Less interest in normal activities
Feeling less sharp
Difficulty remembering people’s names
Difficulty making decisions
Problems finding the right words to communicate
Difficulty solving routine problems
Difficulty learning new things
Problems writing, reading, or organizing thoughts
Difficulty following instructions
2. I experience:
Lack of interest in normal activities
Loss of energy
Oversleeping or sleepiness
Sense of sadness for no apparent reason
Increased appetite, especially for carbohydrates
Fatigue
Symptoms that usually get worse in the winter
Weight gain or weight loss
Difficulty concentrating and processing information, especially in the afternoon
Diminished sexual desire
3. I frequently:
Feel tense and have trouble relaxing
Have headaches and other aches and pains
Get crabby or grouchy
Have trouble falling asleep or staying asleep
Sweat and have hot flashes in anticipation of events
Feel irritable or short tempered
Have trouble letting things go
Get angry for no apparent reason
Women only: Get worse symptoms prior to getting my period
4. I often:
Feel overly active and compelled to do things, like being driven by a motor
Have difficulty relaxing and unwinding when I have time to myself
Misplace and have difficulty finding things
Crave caffeine and stimulants to keep me going
Delay getting started when I have a task or work that requires a lot of thought
Get easily distracted by activity or noise around me
Have difficulty keeping my attention when doing boring and repetitive work
Fidget or squirm with my hands and feet when I have to sit down for a long time
Leave my seat in meetings or other situations in which I am expected to remain seated
Have problems remembering appointments or obligations
Have difficulty concentrating on what people say to me, even when they are speaking to me directly
Move around and kick in my sleep
5. I experience:
Waking up frequently during the night with difficulty returning to sleep
Looking forward to catching up on my sleep on the weekends
Taking more than 30 minutes to fall asleep at night
Stomach problems or nausea
Waking up repeatedly throughout the night
Waking up groggy and not well rested
Preferring to go to sleep later than midnight and waking up late, after 10:00 A.M.
Preferring an early bedtime—going to sleep between
7 P.M. and 9 P.M. and waking up early, around 5:00 A.M.
Jet lag
Difficulty turning off my thoughts when I lay down to sleep
© Metagenics 2006
MET1387 9/06
Additional Comments:
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