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Client Checklist of Concerns

Below is a list of problems that clients frequently describe to us. Please circle any that match your current concerns.

Then please rate each item you circled from 1 to 10 with 1 being a mild concern and 10 being extremely problematic.  

BODY

  • Difficulty falling asleep

  • Wakeful or restless during night

  • Waking up early

  • Difficulty waking up

  • Nightmares or night terrors

  • Snoring

  • Sleep walking

  • Sleep apnea

  • Frequent night waking

  • Sleeps greater than 9 hours

  • Fall asleep in low stimulation

  • Bedwetting advanced age

  • Difficulty completing schoolwork

  • Getting into trouble at school

  • Inverting letters/numbers

  • Spatial problems (e.g. difficult

  • Careless with tasks

  • Difficulty with particular subjects

  • Make mistakes

  • Allergies

  • Asthma

  • Frequent colds, infections

  • Yeast infections

  • Fatigue

  • Chronic Fatigue Syndrome

  • Dislikes caffeine

  • Dislikes alcohol affects

  • Likes alcohol affects

  • Abuses substances

  • Sometimes drink too much

  • Smoke cigarettes

  • Concerns about your diet

  • Desire caffeine

  • Use marijuana

  • Other addictions

  • Inattentive

  • Frequent daydreaming

  • Spaciness

  • Forgetful

  • Confused Thinking

  • Difficult focusing

  • Easily distracted

  • Make mistakes

  • Difficult organizing activities

  • Not completing tasks

  • Lose train of thought

  • Hearing loss

  • Ringing in ears

  • Earaches

  • Sense of smell less or lost

  • Nose or sinuses blocked

  • Grinding your teeth

  • Sense of taste changed

  • Hoarseness or sore throat

  • Nausea or vomiting

  • Gastric pain

  • Gas or bloating

  • Irritable bowel

  • Diarrhea

  • Constipation

  • Double or blurred vision

  • Blind spots

  • Spots in your vision

  • Difficulty urinating

  • Difficulty holding urine

  • Difficult bowel control

  • Freq bladder infections

  • Headaches or migraines

  • Fainting

  • Seizures

  • Memory loss

  • Blocking on words

  • Reading problems

  • Difficult speaking

  • Tremor (shaking)

  • Weakness

  • Hyperactivity

  • Problems with balance

  • Hand/ arm flapping

  • Motor or vocal tics

  • Appetite problems (e.g. wanting to

  • eat when not hungry, etc)

  • Diabetes

  • Desire for sweets or carbohydrates

  • Sensitivity to heat or cold

  • Thyroid problems

  • PMS symptoms

  • Hot flashes

  • Other menopausal symptoms

  • Low interest in sex

  • Excessive interest in sex

  • Problems breathing

  • Heart problems

  • Hypertension

  • Palpitations

  • Dizziness

BEHAVIOUR / EMOTIONS

  1. Depression/sad

  2. Depression/angry

  3. Low self-esteem

  4. Introversion

  5. Excessive shy

  6. Mood swings

  7. Feeling down, depressed or flat

  8. Feeling sad

  9. Feeling anxious

  10. Panic attacks

  11. Worry

  12. Thoughts that won't leave your mind

  13. Need to repeat actions or words over and over

  14. Bingeing

  15. Restricting your food intake

  16. Making yourself vomit

  17. Phobias - avoiding things

  18. Feeling others are against you

  19. Behaviors that get you into trouble or are not good for you

  20. Feeling angry a lot

  21. Impulsive

  22. Feeling overwhelmed

  23. Lethargy

  24. Multiple social conflicts

  25. Low emotional awareness

  26. Multiple relationship issues

  27. Low motivation

  28. Busy mind

  29. Fidgety

  30. Easily bored/Impatient

  31. Agitated

  32. Aggressive

  33. Autism

  34. Early Developmental Trauma

  35. Reactive Attachment Disorder

  36. Bonding Issues

  37. Bipolar diagnosis

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