First Name:
Last Name:

Able to think on your feet Yes No
Getting tired easily Yes No
Task initiation Yes No
Response Inhibition (self control) Yes No
Works slowly or speeds through carelessly Yes No
Perseverates (repeats action and/or comments w/o conscious awareness) Yes No
Procrastinates Yes No
Shifting approaches on demand Yes No
Are you able to pay attention to two things at once? Yes No
Attention and Focus Yes No
Can?t hold several thoughts at one time Yes No
Needing prompting to get on with things Yes No
Losing track in the middle of a conversation Yes No
Missing important details in tasks Yes No
Exercising good judgment Yes No
Identifying personal strengths and weaknesses accurately Yes No
Seeing things from another person?s point of view Yes No
Understanding subtle or abstract communication Yes No
Correcting personal mistakes Yes No
Monitoring personal behavior and adjusting it accordingly Yes No
Adjusting to unexpected changes Yes No
Planning the day Yes No
Starts many things but completes very few of them Yes No
Adding up lists of numbers in head Yes No
Difficulty being quick-witted Yes No
Going off on tangents in conversations Yes No
Can?t hold several thoughts at one time Yes No
Cannot prepare for future events Yes No
Coming up with a formula to reach a conclusion Yes No
Using several components of logic to derive at a solution Yes No
Understanding what steps it takes to solve a problem Yes No
The drawing of a conclusion by reasoning Yes No
Creating plans Yes No
Reasoning through the logic of the problem Yes No
With 'if this?then this' statements Yes No
The arrangement of the words in a sentence? Yes No
Phrases, clauses in sentences? Yes No
Remembering the rules for contractions of words? Yes No
The leaving the endings off words? Yes No
Remembering the specific rules? Ie; 'I before e except after c' Yes No
Poor memory, frequent feeling of being scattered Yes No
Trouble writing, even though they may be able to say what they are thinking Yes No
Slowness in responding Yes No
Having to do things slowly in order to understand them Yes No
Completing complex tasks in the right order Yes No
Often is late or in a hurry Yes No
Problems completing things Yes No
Often appears unmotivated Yes No
Frequently sluggish or slow moving Yes No