Name *
Phone *
The phone number you want us to use to reach you.
Blood pressure measurements are written with the higher number first, a slash, then the lower number. Typical readings vary from 90/60 to 130/80.
Pulse measurements are obtained by recording your pulse for one minute after you have been seated and relaxed more than 5 minutes.
Attention and Organization
1. Difficulty or inefficiency organizing tasks and activities *
2. Easily distracted by extraneous stimuli *
3. Difficulty sustaining attention in tasks or leisure activities *
4. Make decisions impulsively, without considering consequences/outcomes *
5. Poor follow-through on promises or commitments *
6. Likely to drive a motor vehicle much faster than others *
7. Start tasks without reading or listening to directions carefully *
8. Have trouble doing things in their proper order or sequence *
9. Difficulty stopping activities when they should do so *
10. Poor time sense, trouble managing time efficiently *
11. Trouble listening when spoken to directly *
12. Procrastinate or struggle to begin tasks that require sustained mental effort. *
Restlessness and Control of Activity Level
1. Uncomfortable doing things slowly and systematically; rush through activities or tasks *
2. Impatient; hard to wait on others *
3. Difficulty resisting opportunities or temptations *
4. Tend to act without thinking, make important decisions on the spur of the moment *
5. Interrupt others *
6. Difficulty waiting turn, avoid lines, stoplights *
7. Complete others sentences, “jump the gun” in conversation *
8. Require effort to wait turn
9. Talk too much *
10. “On the go”, always moving *
11. Loud *
12. Restless when staying seated is required *
Emotional Self-Management
1. Anxious, worried, stressed *
2. Avoid social situations, people interactions *
3. Short fuse, easily angered *
4. Blurt out or say things without thinking *
5. Easily frustrated *
6. Often wish I could take back comments *
7. Self-centered, forget to think of others *
8. Throw tantrums *
9. Forget manners, impolite *
10. Moods unpredictable *
11. Feelings of hopelessness *
12. Loss of interest in pleasurable activities *
1. Not Sure of Self *
2. Wish I had greater self-confidence *
3. Disbelieve positive feedback from others *
4. Act OK outside but unsure of self *
5. Feel unhappy *
6. Avoid new challenges *

CONFIDENTIALITY NOTICE: Email and text messaging systems do not meet the level of security recommended in the HIPAA legislation.  We make these forms of communication available to individuals who prefer convenience at the expense of security.  Phone and fax communications satisfy HIPAA regulations and are preferred for those who require this standardized level of privacy.