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    Check all that you have experienced SIGNIFICANTLY:
    Section 1
    ADHD (Inattentive without Impulsivity Subtype)InattentionDaydreamingPoor concentrationLack of motivationNight sweatsFrequent waking during night (without agitation)Sleeping lightlySleeping too muchSleep apneaSnoringNot rested after sleepWaking earlyDifficulty falling asleep AND your mind is quiet.Anxiety (worry)Depression (blue, low, helpless and hopeless)IrritabilityFeelings easily hurtPerfectionistRemorseful after tantrumsCries easily (feelings hurt)RuminationGuiltWithdraws when stressedPassiveGrumpyLow Self-Esteem, Thinks little of selfPerformance anxietyShySeasonal affective disorderFidgetsWhiningTired, listlessObsessive thoughtsDyslexiaIndecisivenessPoor word fluencyPoor sequential processingPoor sequential planningPoor reading comprehensionDifficulty decoding wordsPoor arithmetic calculationChronic pain with depressionChronic aching painTension headacheLow pain thresholdLeft-brain seizuresLeft-brain strokeLeft-brain TBI (traumatic brain injury)Right body paralysis or paresisEnuresis (urinary incontinence)Sugar cravingImmune deficiencyLow thyroid functionPMS-Depressive symptoms: —Irritability —Insomnia —Sugar craving —Cramps —PainPostpartum depressionInsomniaIntolerant of alcohol, other sedative drugs
    Section 1 Comments or Questions

    Section 2
    ADHD Mixed Type with BOTH Attention Deficit and HyperactivityHyperactivity after sugarHyperactivity after sedativesOverwhelmed by stimuliHard to make decisions (executive function)DisorganizedNight terrorsNocturnal myoclonus (jerking or moving while asleep)SleepwalkingSleep talkingNarcolepsy (falling asleep frequently or suddenly)Too busy to sleep (manic quality)Night sweatsBed-wetting (enuresis)Sleep paralysis when awakening; stillDreaming when awakeBinge eatingAnorexiaBulimiaPanic attacksEncopresis (soiling)Irritable bowel syndrome (IBS)Bipolar disorderDissociative identity disorder (DID)Borderline personality disorder (BPD)Posttraumatic stress disorder (PTSD)Developmental traumaRagesAntisocial personality disorder (APD)FibromyalgiaReflex sympathetic dystrophy (RSD)Trigeminal neuralgiaMigraineHeadachesJaw tensionMotion sicknessGeneralized seizuresAbsence (petit mal) seizuresTonic–clonic (grand mal) seizuresTemporal lobe epilepsyTBI with brainstem injuryVertigoTinnitusMotion sicknessTicsHypertensionHypotensionIncontinenceSevere PMS (mood swings, migraines)Chronic fatigue syndrome (CFS)Irritable bowel syndrome (IBS)Type 1 diabetesLupusRheumatoid arthritisCrohn’s diseaseMultiple sclerosisIntolerant of coffee AND alcohol AND many medicationsMultiple chemical sensitivitiesAsthma
    Section 2 Comments or Questions

    Section 3
    ImpulsivityDistractibilityStimulus seekingThrill seekingCompeting thoughts; too many thoughtsDifficulty falling asleep because mind is busyHot flashes during sleepPhysically restless sleepNightmares (bad dreams)Bruxism (teeth grinding)Restless leg syndromeVivid dreamsClenching jawWaking with agitationVigilant sleepAnxiety (fear)AgitationManiaParanoiaSuicidal thoughts or actionsShameCompulsive behaviorInvoluntary movements or ticsImpatientAggressive; initiates conflictJealous/enviousAngryLacks remorseHates selfDissociativeExhaustedLacks empathyLacks cause-and-effect thinkingManipulative, controllingHolds a grudgePoor comprehension and expression of emotionsLacks body awareness (pain, discomfort, appetite)High pain thresholdLoud, unmodulated voicePoor eye contactPoor social awarenessAutistic symptomsHumorlessRoad rageHair pulling or twirlingNail biting, nervous habitsAttachment disorder (historical)Developmental traumaNonverbal learning disabilitiesPoor spellingPoor visual–spatial skillsPoor sense of self in spacePoor tracking during readingLack of prosody in speech (speaks in monotone)Poor drawingLoud voiceInability to write neatly (even when writing slowly)Poor fine motor skillsPoor sense of directionPoor math conceptsLeft and right are not automaticChronic burning painChronic throbbing painChronic stabbing painChronic shooting painSciatic painPeripheral neuropathy painEmotional reactivity to painRefluxRight-brain partial seizuresRight-brain strokeRight-brain TBILeft body paralysis or paresisSpasticityTremorPoor balancePoor coordinationInvoluntary regurgitationNervous habits/laughHiccupsIrregular menstrual periodsRacing thoughtsMania, ragePMS—high arousal symptoms: —Agitation —Mania —Rages —Racing thoughtsMenopausal hot flashesSkin allergies, eczemaHeart palpitationsPounding, racing heartConstipationIntolerant of coffee and other stimulants
    Section 3 Comments or Questions