CNS Functioning Assessment

The CNS Functioning Assessment

Name ______Date of Birth ______Age _____

Today's Date ______Time ______Diagnosis ______

Are you able to drive a motor vehicle? Yes Partially No

Are you able to work or study? Yes Partially No

Are you able to sustain a close relationship with someone? Yes Partially No ______

Below is a list of problems. How frequently are you currently bothered by them? Please pick a number from 0-to-10. “0” means Not at all, and “9” means All the time.

If one or more of your parents had this, place a P in the column headed by “Parents?”

If the problem came on suddenly, put an S in the column head by “Suddenly?”

Complete only once

Sensory Frequency (0 - 9) Parents? Suddenly?

Light, in general, or lights, bother you ______

Problems with the sense of smell ______

Problems with vision ______

Problems with hearing ______

Problems with the sense of touch ______

Emotions

Problems of sudden, unexplained changes in mood ______

Problems of sudden, unexplained fearfulness ______

Problems of unexplained spells of depression ______

Problems of unexplained spells of elation ______

Problems with explosiveness ______

Problems with suicidal thoughts or actions ______

Clarity

Feel “foggy” and have problems with clarity ______

Problems following conversations

(with good hearing) ______

Problems with confusion ______

Problems following what you are reading ______

Realize you have no idea what you have been reading______

Problems with concentration ______

Problems with attention ______

Problems with sequencing ______

Problems with prioritizing ______

Frequency (0 - 9) Parents? Suddenly?

Problems not finishing what you start ______

Problems organizing your room, office, paperwork ______

You cover up that you don't know what was said

or asked of you ______

Energy

Problems with stamina ______

Fatigue during the day ______

Trouble sleeping at night ______

Problems awakening at night ______

Problems falling asleep again ______

Activation or Anxiety

Restlessness ______

Problems with irritability ______

Day Dreaming ______

Worrying ______

Always moving ______

Cold hands or feet ______

Palpitations ______

Memory

Forget what you have just heard ______

Forget what you are doing, what you need to do ______

Problems with procrastination and lack of initiative ______

Problems not learning from experience ______

Movement

Problems with paralysis of one or more limbs ______

Problems focusing or converging the eyes ______

Pain

Head pain that is steady ______

Head pain that is throbbing ______

Shoulder and neck pain ______

Wrist pain ______

Tender areas of muscles ______

All-over pain ______

Joint pain ______

Other pain ______(specify) ______