Progress Tracking Tools
D
TRACKING YOUR SHIFTS:
THE ONE HUNDRED
TIP:
Getting the DIFS (Duration/Intensity
and Frequency) for any item not included on
the “Tracking Your Shifts” Sheet can be handy
to use for comparison down the road.
Tracking Progress
5
Client Instructions:
Circle any item that currently pertains to you. If you
aren’t sure if you should circle something or not,
use the last week as a guide.
Trainer Instructions:
When they hand you back the completed form add
up the items and write down the number.
www.neuroptimal.com
Please check off any item that represents how you are feeling so you can track brain perception following your use of NeurOptimal
®
. If you are unsure,
use the past week as your guide. It’s fine to add comments if you wish. Please note that NeurOptimal
®
does not diagnose, treat, mitigate or cure any
disease, disorder or abnormal physical state. This checklist is provided for tracking and reference purposes only. If you require a diagnosis or treatment
for any of the below feelings, you should seek medical advice.
1.
Itchy or irritated nose, sneezing
2.
Wheezing
3.
Catch cold too often
4.
Run down
5.
Tired
6.
Awake too long when you go to bed
7.
Waking up during the night
8.
Waking up before you want to
9.
Difficult to wake up in the morning
10.
Bad dreams
11.
Difficulty breathing at night
12.
Out of bed but not knowing how you got there
13.
Skin difficult to manage
14.
Hair weaker or less lustrous than you’d like
15.
Nails weak, flaking or tearing
16.
Blurry vision at times
17.
Areas where you can’t see anything
18.
Spots floating in front of you
19.
Difficult to hear
20.
Ringing in your ears
21.
Ears hurt inside
22.
Smells seem different or lost
23.
Nose gets blocked
24.
Grinding your teeth
25.
Things taste different
26.
Voice hoarse or sore
27.
Can’t get enough air
28.
Heart too fast or jumpy
29.
Pulsing or throbbing in your head
30.
Heart skips a beat
31.
World spinning around you
32.
Might throw up
33.
Tummy hurts
34.
Gassy, bloated
35.
Sensitive digestion
36.
Upset stomach
37.
Difficulty going to the bathroom
38.
Eat when not hungry, or
not feeling hungry
39.
Trouble eating sweets
40.
Urges to eat sweet things
41.
Sensitive to heat or cold
42.
Slowed down or speeded up
43.
Moody at certain times of the month
44.
Hot flashes
45.
Problems from being of a “certain age”
46.
Not interested in your partner
47.
Too interested in your partner or
other people?
48.
Stiff and sore
49.
Areas that really hurt
when touched
50.
Muscles hurt
51.
Fatigued
52.
Pains in your head
53.
Going to pass out
54.
Lose consciousness
55.
Difficult to remember things
56.
Difficult to find your words
57.
Difficulty reading
58.
Difficult to speak sometimes?
59.
Shaky
60.
Weak
61.
Too active
62.
Can’t balance on one leg
63.
Moving your head or saying
words you don’t intend
64.
Difficulty paying attention
65.
Easily distracted
66.
Make a lot of mistakes
67.
Disorganized
68.
Difficult to complete tasks
69.
Lose your train of thought
70.
Difficult to complete studies or work
71.
Get into trouble at school or work
72.
Mix up numbers or letters sometimes
73.
Difficult to know how things fit together
74.
Difficulty with some subjects
75.
Need to go to the bathroom but hard to start
76.
Lose your urine sometimes
77.
Difficult to control going to the toilet
78.
Stinging sensations when going to the bathroom
79.
Drink too much sometimes
80.
Smoke cigarettes
81.
Concerns about eating
82.
Need caffeine to get going
83.
Enjoy marijuana
84.
Habits that concern you
85.
Moody
86.
Feeling low or flat
87.
Feel sad
88.
Concerned about things
89.
Feel terrified sometimes
90.
Mull about things
91.
Thoughts you’d like to stop but can’t
92.
Need to do things over and over
93.
Eat more food than you can comfortably eat
94.
Careful to never eat too much
95.
Make yourself throw up
96.
Difficult to do things you’d like to do
97.
Others are against you
98.
Get into trouble for your behavior
99.
Feeling angry
100.
Overwhelmed
Note:
Any concerns mentioned are intended as examples only and not meant to suggest that NeurOptimal® treats, mitigates, cures, or diagnoses any listed concern.
Instead, identified concerns and medication use are one of many ways to measure shifts in brain functioning and perception.
TRACKING YOUR SHIFTS:
THE ONE HUNDRED
NAME:
DATE:
PRE/ONGOING/POST
SESSION#:
23
