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Step 1 of 4
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Step 1 of 4 Trainee Information
Trainee Name
*
Trainee Email
*
Date of Birth
*
Month
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1922
1921
1920
Gender
*
Male
Female
Step 2 of 4 Personal Information & Physical
Trainee grew up in (check all that apply)
Birth Family
Adoptive Family
Foster Family
Is there a history of?
Separated from birth mother < age 2
Distant or absent parents early in life
Neglect
Abuse
other
Other Trauma
Number of Siblings (including trainee)
*
Select a value
1
2
3
4
5
6
7
8
9
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11
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17
18
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25
Trainee's place in family birth order
*
Select a value
1
2
3
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5
6
7
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25
Schooling completed
*
Select a value
None
Some school
High School
Undergraduate degree
Graduate degree
Graduate degree
Occupation
Which is the trainee's dominant hand?
*
Select a value
Left hand
Right hand
Some of each
Medications
How many of these medications do you take daily?
Antidepressants
*
Select a value
0
1
2
3
4
5
>5
Anti-anxiety
*
Select a value
0
1
2
3
4
5
>5
Anticonvulsants
*
Select a value
0
1
2
3
4
5
>5
Antipsychotics
*
Select a value
0
1
2
3
4
5
>5
Stimulants
*
Select a value
0
1
2
3
4
5
>5
Mood stabilizers
*
Select a value
0
1
2
3
4
5
>5
Do you now or have you in the past drunk alcoholic beverages?
*
Select a value
Occasionally in the past
Regularly in the past but no longer
Currently drink
No
Alcohol Frequency
*
Select a value
1-12 x/year
1-4 x/month
1-2 x/week
3-4 x/week
>3-4 x/week
Do you now or have you in the past used recreational drugs?
*
Select a value
Yes, experimented in the past
Yes, used regularly in the past but no longer
Currently use
No
Recreational Drugs Frequency
*
Select a value
1-12 x/year
1-4 x/month
1-2 x/week
3-4 x/week
>3-4 x/week
Conditions
Have you suffered a head injury?
*
Select a value
Yes, with loss of consciousness
Yes, with symptoms following injury
Yes, multiple times
No
Do you now or have you ever had seizures?
*
Select a value
Had in the past, no longer have them
Currently have, controlled by medication
Currently have, uncontrolled
No
Check applicable boxes below
Autistic spectrum
Nonverbal
Language delay
Parkinson's disease
Please list any drugs (prescribed or recreational) regularly taken or leave blank.
Things I would like to change
Autonomic
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Migraines
0
1
2
3
4
5
Irritable bowel
0
1
2
3
4
5
Panic Attacks
0
1
2
3
4
5
Allergies or asthma
0
1
2
3
4
5
Tinnitus
0
1
2
3
4
5
Cold hands/feet
0
1
2
3
4
5
Dull, chronic pains
0
1
2
3
4
5
Tics/involuntary movements or vocalizations
0
1
2
3
4
5
Tremors
0
1
2
3
4
5
Experiences racing heartbeat
0
1
2
3
4
5
Sharp shooting pains
0
1
2
3
4
5
Fibromyalgia
0
1
2
3
4
5
Chronically fatigued
0
1
2
3
4
5
Hot flashes or chills
0
1
2
3
4
5
Sensitivity to touch, light or sound
0
1
2
3
4
5
Closes off to sensory awareness
0
1
2
3
4
5
Does not like to be touched or held
0
1
2
3
4
5
Sleep
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Has trouble falling asleep
0
1
2
3
4
5
Wakes often during the night
0
1
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3
4
5
Hard to awaken/never feel rested
0
1
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3
4
5
Wakes at night and can't sleep again
0
1
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3
4
5
Moves around a lot while sleeping
0
1
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3
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5
Grinds teeth in sleep
0
1
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3
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5
Wets the bed
0
1
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3
4
5
Sleep walks
0
1
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3
4
5
Nightmares or night terrors
0
1
2
3
4
5
Night sweats
0
1
2
3
4
5
Step 3 of 4 Social & Issues related to mood
Things I would like to change
Social
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Misses cues in social situations
0
1
2
3
4
5
Difficulty forming or sustaining relationships
0
1
2
3
4
5
Misses non-verbal meaning of communication
0
1
2
3
4
5
Inability to feel others' emotions
0
1
2
3
4
5
Needs to be the center of attention
0
1
2
3
4
5
Does not accept authority
0
1
2
3
4
5
Argumentative
0
1
2
3
4
5
Issues related to mood
Stress
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Overreacts to pressure
0
1
2
3
4
5
Can't quiet the mind
0
1
2
3
4
5
Speaks very fast
0
1
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3
4
5
Talks excessively
0
1
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3
4
5
Expects perfection of self/others
0
1
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3
4
5
Physically tense
0
1
2
3
4
5
Speaks quietly or slowly
0
1
2
3
4
5
Frequent tension headaches
0
1
2
3
4
5
Anxiety
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Often worried/anxious
0
1
2
3
4
5
Relatively constant anxiety
0
1
2
3
4
5
Tends to expect the worst
0
1
2
3
4
5
Judges self negatively
0
1
2
3
4
5
Shy or withdrawn in social situations
0
1
2
3
4
5
Trembling, twitching, shakiness
0
1
2
3
4
5
Feels on edge
0
1
2
3
4
5
Easily startled
0
1
2
3
4
5
Avoids places where he/she might be anxious
0
1
2
3
4
5
Frequent thoughts of danger
0
1
2
3
4
5
Sees self as unable to cope
0
1
2
3
4
5
Thoughts of something terrible happening
0
1
2
3
4
5
Depression
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Energy levels are low
0
1
2
3
4
5
Feels helpless or hopeless
0
1
2
3
4
5
Cries easily
0
1
2
3
4
5
Apathetic or indifferent
0
1
2
3
4
5
Flat emotional response to positive events
0
1
2
3
4
5
Seems lazy
0
1
2
3
4
5
Weight loss or gain
0
1
2
3
4
5
Decreased sexual desire
0
1
2
3
4
5
Easily tired
0
1
2
3
4
5
Trouble swallowing/lump in the throat
0
1
2
3
4
5
Less interest or pleasure in usual activities
0
1
2
3
4
5
Withdraws from or avoids people
0
1
2
3
4
5
Finds it harder than usual to do things
0
1
2
3
4
5
Sees self as worthless
0
1
2
3
4
5
Difficulty making decisions
0
1
2
3
4
5
Suicidal thoughts or plans
0
1
2
3
4
5
Recurrent thoughts of death
0
1
2
3
4
5
Low self esteem
0
1
2
3
4
5
Self-critical thoughts
0
1
2
3
4
5
Feels guilty or ashamed
0
1
2
3
4
5
Anger
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Has an explosive temper
0
1
2
3
4
5
Explosive emotional reactions to minor events
0
1
2
3
4
5
Irritable/impatient
0
1
2
3
4
5
Reacts with physical violence
0
1
2
3
4
5
Feels bitter/negative
0
1
2
3
4
5
Anger outbursts after slow build-up
0
1
2
3
4
5
Easily agitated
0
1
2
3
4
5
Aggressive anger or irritability
0
1
2
3
4
5
Outbursts of rage without cause
0
1
2
3
4
5
Perceives events negatively
0
1
2
3
4
5
Fear
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Often afraid
0
1
2
3
4
5
Paranoid thoughts
0
1
2
3
4
5
Afraid in situations when others are not
0
1
2
3
4
5
Step 4 of 4 Issues related to cognition
Attention
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Drifts off into thoughts when working
0
1
2
3
4
5
Easily distracted from tasks
0
1
2
3
4
5
Puts off starting assigned tasks
0
1
2
3
4
5
Doesn't finish assigned tasks until the deadline
0
1
2
3
4
5
Can't finish assigned tasks
0
1
2
3
4
5
Difficulty completing tasks with multiple steps
0
1
2
3
4
5
Works very slowly to be sure things are right
0
1
2
3
4
5
Self-Control
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Stubborn
0
1
2
3
4
5
Acts/speaks impulsively
0
1
2
3
4
5
Speaks quickly or loudly or interrupts
0
1
2
3
4
5
Impatient, seeks stimulation, easily bored
0
1
2
3
4
5
Tends to have quick emotional responses
0
1
2
3
4
5
Fidgety, restless or hyperactive
0
1
2
3
4
5
Handwriting is sloppy
0
1
2
3
4
5
Tends to be clumsy/accident prone
0
1
2
3
4
5
Can't control use of substances
0
1
2
3
4
5
Driven to repetitive/compulsive behaviors
0
1
2
3
4
5
Rigid thought; gets stuck on an idea
0
1
2
3
4
5
Phobias or irrational fears
0
1
2
3
4
5
Obsessive thoughts or fears
0
1
2
3
4
5
Addictive behaviors
0
1
2
3
4
5
Oppositional/defiant
0
1
2
3
4
5
Dominant or demanding in relationships
0
1
2
3
4
5
Argues frequently; doesn't give in
0
1
2
3
4
5
Eating disorders
0
1
2
3
4
5
Eats too little
0
1
2
3
4
5
Eats too much
0
1
2
3
4
5
Holds a grudge or dislikes change
0
1
2
3
4
5
Self injury/cutting
0
1
2
3
4
5
Pulls out hair
0
1
2
3
4
5
Inappropriate sexual activity
0
1
2
3
4
5
Creativity
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Concrete thinking
0
1
2
3
4
5
Doesn't do well with tasks involving novelty
0
1
2
3
4
5
Avoids creative tasks
0
1
2
3
4
5
Doesn't enjoy fiction, arts
0
1
2
3
4
5
Has difficulty seeing context
0
1
2
3
4
5
Learning
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Has a hard time listening for detail
0
1
2
3
4
5
Has a hard time reading for detail
0
1
2
3
4
5
Rushes tasks, makes silly mistakes
0
1
2
3
4
5
Makes careless math errors
0
1
2
3
4
5
Can't get math concepts
0
1
2
3
4
5
Doesn't stay on track when speaking/writing
0
1
2
3
4
5
Reverses letters/numbers
0
1
2
3
4
5
Dyslexia
0
1
2
3
4
5
Stutters
0
1
2
3
4
5
Memory
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Quickly forgets what is read/heard
0
1
2
3
4
5
Quickly forgets tasks or learned material
0
1
2
3
4
5
Can't remember past events
0
1
2
3
4
5
Forgets faces/names
0
1
2
3
4
5
Old memories keep intruding into thoughts
0
1
2
3
4
5
Cannot recall periods of time from the past
0
1
2
3
4
5
Thinking
In areas that are problems, please rate how much of a problem they are for you, from 0-5 0=Not an issue, 1=Minor issue, 5=Major issue
Hyperfocuses or has difficulty changing tasks
0
1
2
3
4
5
Difficulty balancing multiple tasks or assignments
0
1
2
3
4
5
Highly detail oriented or structured
0
1
2
3
4
5
Productive but gets worn down by workload
0
1
2
3
4
5
Hears voices inside head
0
1
2
3
4
5
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