Home
Services
Pediatric Occupational Therapy and Sensory Integration
Neurofeedback
Biofeedback
Adult Occupational Therapy Services
Pediatric Physical Therapy
Constraint Induced Movement Therapy
LSVT BIG®
Research Articles
Our Staff
Forms
Contact
Weekly Neurofeedback tracking form
Home
Weekly Neurofeedback tracking form
Weekly Neurofeedback Tracking System
Name:
Date:
If child, form completed by:
Relation to child:
Please rate the following items on the following scale: 1= Never 2= Rarely 3= Sometimes 4= Often 5= Always
Inefficient in self quieting, Inability to shut off brain, Racing thoughts
1
2
3
4
5
Poor stress tolerance
1
2
3
4
5
Personality Changes
1
2
3
4
5
More attentive to internal state than external environment/ relationships
1
2
3
4
5
General tendency towards anxiety
1
2
3
4
5
Burnout Depression
1
2
3
4
5
Self-medicating behaviors (i.e. food, coffee, OTC medications)
1
2
3
4
5
Foggy Thinking
1
2
3
4
5
Mental Sluggishness
1
2
3
4
5
Attention Difficulties
1
2
3
4
5
Easily frightened
1
2
3
4
5
Stubborn
1
2
3
4
5
Tires easily while reading
1
2
3
4
5
Problems with reading comprehension and retention
1
2
3
4
5
Visual processing/memory problems
1
2
3
4
5
Poor short term memory
1
2
3
4
5
Past or present exposure to severe emotional stressors
1
2
3
4
5
Problems with concentration
1
2
3
4
5
Physical pain (chronic, lingering, inexplicable pain)
1
2
3
4
5
Forgetfulness
1
2
3
4
5
Problems with memory
1
2
3
4
5
Obsessive compulsive tendencies
1
2
3
4
5
Emotional Volatility
1
2
3
4
5
Restricted emotional range
1
2
3
5
4
Impulse control difficulties
1
2
3
4
5
Depression or predisposition to depressed mood states
1
2
3
4
5
Talkativeness, selective and sustained attention
1
2
3
4
5
Problems with organization, sequencing, planning, completing tasks
1
2
3
4
5
Frequently ill, frightened, unhappy, unmotivated (children only)
1
2
3
4
5
Problems with sleep quality
1
2
3
4
5
Vulnerable to colds and flu
1
2
3
4
5
Difficulty with motivation
1
2
3
4
5
Oversensitive
1
2
3
4
5
Irritability
1
2
3
4
5
Intrusive behavior
1
2
3
4
5
Overly forward in social situations
1
2
3
4
5
Overly avoidant in social situations
1
2
3
4
5
Tendency towards mania
1
2
3
4
5
Tactlessness
1
2
3
4
5
Difficulty filtering information (divided and selective attention)
1
2
3
4
5
Difficulty with word retrieval
1
2
3
4
5
Speech intonation and Rhythm abnormalities
1
2
3
4
5
Working memory difficulty- spatial & visual
1
2
3
4
5
Difficulty understanding facial expressions/ reading others emotions
1
2
3
4
5
Difficulty recognizing people
1
2
3
4
5
Difficulty with planning or problem solving
1
2
3
4
5
Poor speech skills
1
2
3
4
5
Lack of interest, enthusiasm or concern
1
2
3
4
5
Noticeable difficulty with sensory motor skills
1
2
3
4
5
Difficulty understanding language
1
2
3
4
5
Diminished long term memory relating to declarative and episodic processing
1
2
3
4
5
Tendency towards sounding emotionally sounding emotionally angry or sad
1
2
3
4
5
Difficulty visualizing an event and reporting in sequence
1
2
3
4
5
Acalculia- Difficulty with arithmetic
1
2
3
4
5
Difficulty in constructing meaning from something
1
2
3
4
5
Tendency towards over-thinking
1
2
3
4
5
Difficulty organizing/ categorizing/ sorting through information
1
2
3
4
5
Difficulty recalling phone numbers or information made up of digit spans
1
2
3
4
5
Excessive self concern or tendency towards having a victim mentality
1
2
3
4
5
Difficulty understanding boundaries
1
2
3
4
5
Difficulty interpreting sensations (touch, body awareness)
1
2
3
4
5
Apraxia (Difficulty planning and initiating body movement)
1
2
3
4
5
Tendency towards preservation (lack of mental shifting)
1
2
3
4
5
Poor self awareness
1
2
3
4
5
Decreased procedural memory ( step by step actions taken to do something)
1
2
3
4
5
Additional comments:
