NFBThailand's Neurofeedback Assessment Questionnaire
Email address *
Date *
MM
/
DD
/
YYYY
Full name *
Your answer
ID Number *
ex: S8311901G
Your answer
Born *
MM
/
DD
/
YYYY
Age *
ex. 23
Your answer
Phone Number *
Area Code - Phone Number
Your answer
Address
*
Street address
Your answer
Question *
Town, City
Your answer
*
Postal Code
Your answer
Country *
It is important to know whether you have any of these symptoms presently, or have ever had them. If the symptom is not a current problem but you have had the symptom in the past, check the minor problem box.
*
No Problem
Minor or Past Problem
Moderate Problem
Significant Problem
Major Problem
Bruxism (teeth grinding)
Difficulty maintaining sleep
Dis-regulated sleep cycle
Night sweats (hypoglycemic)
Nightmares or vivid dreams
Periodic leg movements
Restless sleep
Sleep walking
Sleep talking
Difficulty falling asleep
Difficulty waking
Narcolepsy (falling asleep frequently and/or suddenly)
Night terrors—w/screaming, don't remember in morning
Restless leg
Sleep apnea
Snoring
How long does it take for you to fall asleep? *
Your answer
How many hours of sleep do you get a night? *
Your answer
What time do you tend to go to bed? *
Time
:
What time do you tend to get up? *
Time
:
Attention and Learning Symptoms *
No Problem
Minor or Past Problem
Moderate Problem
Significant Problem
Major Problem
Difficulty completing tasks
Difficulty making decisions
Difficulty remembering names
Difficulty shifting tasks
Difficulty understanding conversations
Lack of Alertness
Messy Handwriting
Poor concentration
Poor math
Poor sustained attention
Poor vocabulary
Reading difficulty
Unmotivated
Difficulty following directions
Difficulty organizing personal time or space
Difficulty shifting attention
Difficulty thinking clearly
Distractibility
Lacking common sense
Not listening
Poor drawing skills
Poor short term memory
Poor verbal expression
Poor word finding
Slow thinker
Sensory *
No Problem
Minor or Past Problem
Moderate Problem
Significant Problem
Major Problem
Auditory Sensitivity
Motion Sickness
Pain anywhere in the body
Tinnitus
Visual Deficits
Chemical sensitivities
Poor body awareness
Tactile hypersensitivity
Vertigo
Visual hypersensitivity
Behavioral *
No problem
Minor or Past Problem
Moderate Problem
Significant Problem
Major Problem
Addictive Behaviors
Anorexia
Binging and purging
Compulsive behaviors
Crying
Hyperactivity
Inflexibility
Lack of sense of humor
Manipulative behavior
Nail biting
Poor eye contact
Poor social or emotional reciprocity
Rages
Stuttering
Aggressive behavior
Autistic stimmming
Class clown
Compulsive eating
Excessive talking
Impulsivity
Lack of appetite awareness
Lack or social interest
Motor or vocal tics
Oppositional or defiant behavior
Poor grooming
Poor speech articulation
Self-injurious behavior
EMOTIONAL *
No Problem
Minor or Past Problem
Moderate Problem
Significant Problem
Major Problem
Agitation
Anxiety
Difficult to soothe
Easily Embarrassed
Fears
Flashbacks of trauma
Irritability
Lack of pleasure