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Brain Noise
Step
1
of
6
16%
Pressure (Stress) Levels
Answer each of the questions below by placing a check in the appropriate column for "yes" or "no". Answer the question in terms of your own personal experiences and feelings during the past twelve months.
Coach Name
*
First
Last
Client Name
*
First
Last
Date Questionnaire Completed
*
DD slash MM slash YYYY
1. Have you lived or worked in a noisy area?
*
No
Yes
2. Have you changed your living conditions or moved?
*
No
Yes
3. Have you had trouble with in-laws?
*
No
Yes
4. Have you taken out a large loan or mortgage?
*
No
Yes
5. Have you tended to fall behind with the things you should do?
*
No
Yes
6. Have you found it difficult to concentrate at times?
*
No
Yes
7. Have you frequently had trouble going to sleep?
*
No
Yes
8. Have you found that you tend to eat, drink or smoke more than you really should?
*
No
Yes
9. Have you watched 3 or more hours of television daily for weeks at a time?
*
No
Yes
10. Have you or your spouse changed jobs or work responsibilities?
*
No
Yes
11. Have you been dissatisfied or unhappy with your work or felt excessive work responsibility?
*
No
Yes
12. Has a close friend died?
*
No
Yes
13. Have you been dissatisfied with your sex life?
*
No
Yes
14. Have you been pregnant?
*
No
Yes
15. Have you had an addition to the family?
*
No
Yes
16. Have you worried about making ends meet?
*
No
Yes
17. Has one of the family had bad health?
*
No
Yes
18. Have you taken tranquilizers from time to time?
*
No
Yes
19. Have you frequently found yourself becoming easily irritated when things don't go well?
*
No
Yes
20. Have you often experienced bungled human relations - even with those you love most?
*
No
Yes
21. Have you found that you're often impatient or edgy with your children or other family members?
*
No
Yes
22. Have you tended to feel restless or nervous a lot of the time?
*
No
Yes
23. Have you had frequent headaches or digestive upsets?
*
No
Yes
24. Have you experienced anxiety or worry for days at a time?
*
No
Yes
25. Have you often been so preoccupied that you have forgotton where you've put things (such as keys) or forgotton whether you've turned off appliances on leaving home or office?
*
No
Yes
26. Have you been married or reconciled with your spouse?
*
No
Yes
27. Have you had a serious accident, illness or surgery?
*
No
Yes
28. Has anyone in your immediate family died?
*
No
Yes
29. have you divorced or seperated?
*
No
Yes
Motivation (Stimulation) Levels
Below you will find a series of paired statements which you are asked to regard as choices. In some cases you will like both choices. In some cases you will dislike both choices. In other cases you will find the choices neutral. No matter how the items strike you, you are to quickly choose which of the alternatives you prefer in comparison to the other alternative.
Question 1.
*
A. See a war drama
B. See a situation comedy
Question 2.
*
A. Play sports requiring endurance
B. Play games with rest stops
Question 3.
*
A. Raunchy blues
B. Straight ballads
Question 4.
*
A. Jazz combo
B. 1001 Strings
Question 5.
*
A. Stereo on too loud
B. Stereo on too low
Question 6.
*
A. Own a goldfish
B. Own a turtle
Question 7.
*
A. Conservatism
B. Militantism
Question 8.
*
A. Too much sleep
B. Too little sleep
Question 9.
*
A. Danger
B. Domesticity
Question 10.
*
A. Passanger car
B. Sports car
Question 11.
*
A. Have several pets
B. Have one pet
Question 12.
*
A. Be a shepherd
B. Have one pet
Question 13.
*
A. Motor scooter
B. Motorcycle
Question 14.
*
A. See the movie
B. Read the book
Question 15.
*
A. Cocktail music
B. Disco music
Question 16.
*
A. Do research in the library
B. Attend a classroom lecture
Question 17.
*
A. A hot drink
B. A warm drink
Question 18.
*
A. Drum solo
B. A string solo
Question 19.
*
A. Too much exercise
B. Too little exercise
Question 20.
*
A. Loud music
B. Quiet music
Question 21.
*
A. Prepare medications
B. Dress wounds
Question 22.
*
A. A driving boat
B. A nice melody
Question 23.
*
A. Hard rock music
B. Regular pop music
Question 24.
*
A. Like athletics
B. Dislike athletics
Question 25.
*
A. Unamplified music
B. Electrically amplified music
Question 26.
*
A. Smooth-textured foods
B. Crunchy foods
Question 27.
*
A. Mind expanding drugs
B. Alcohol
Question 28.
*
A. Speed
B. Safety
Question 29.
*
A. The Beatles
B. Dean Martin
Question 30.
*
A. Soccer
B. Golf
Question 31.
*
A. Excitement
B. Calm
Question 32.
*
A. A family of six
B. A family of twelve
Question 33.
*
A. Thrills
B. Tranquility
Question 34.
*
A. Play contact sports
B. Play noncontact sports
Question 35.
*
A. Live in a crowded home
B. Live alone
Question 36.
*
A. Share intimacy
B. Share affection
Question 37.
*
A. Games emphasizing speed
B. Games paced slowly
Question 38.
*
A. Thinking
B. Doing
Question 39.
*
A. Competitive sports
B. Noncompetitive sports
Question 40.
*
A. Emotionally expressive, somewhat unstable people
B. Calm, even-tempered people
Question 41.
*
A. Be a nurse on an acute ward care
B. Be a nursing supervisor
Question 42.
*
A. Be a NASA scientist
B. Be an astronaut
Question 43.
*
A. Be a stuntman
B. Be a propman
Question 44.
*
A. A job which requires a lot of travelling
B. A job which keeps you in one place
Question 45.
*
A. Climb on a mountain
B. Read about a dangerous adventure
Question 46.
*
A. Body odors are disgusting
B. Body odors are appealing
Question 47.
*
A. Keep on the move
B. Spend time relaxing
Question 48.
*
A. Have a cold drink
B. Have a cool drink
Question 49.
*
A. Being confined alone in a room
B. Being free in the desert
Question 50.
*
A. Security
B. Excitement
Question 51.
*
A. Continuous anesthesia
B. Continuous hallucinations
Question 52.
*
A. Water skiing
B. Boat rowing
Question 53.
*
A. Hostility
B. Conformity
Question 54.
*
A. Renoir
B. Picasso
Life Satisfaction (Contentment) Scales
This questionnaire is designed to measure the degree of contentment that you feel about your life and surroundings. It is not a test, so there are no right or wrong answers. Answer each item as carefully and accurately as you can by placing a number beside each one as follows:
1 = Rarely or none.
2 = A little of the time
3 = Some of the time
4 = A good part of the time
5 = Most of the time
1. I feel powerless to do anything in my life.
*
1
2
3
4
5
2. I feel blue.
*
1
2
3
4
5
3. I am restless and can't keep still.
*
1
2
3
4
5
4. I have crying spells
*
1
2
3
4
5
5. It is easy for me to relax.
*
1
2
3
4
5
6. I have a hard time getting started on things i need to do.
*
1
2
3
4
5
7. I do not sleep well at night.
*
1
2
3
4
5
8. When things get tough, I feel there is always someone I can turn to.
*
1
2
3
4
5
9. I feel that the future looks bright for me.
*
1
2
3
4
5
10. I feel downhearted.
*
1
2
3
4
5
11. I feel that i am needed.
*
1
2
3
4
5
12. I feel that i am appreciated by others.
*
1
2
3
4
5
13. I enjoy being active and busy.
*
1
2
3
4
5
14. I feel that others would be better off without me.
*
1
2
3
4
5
15. I enjoy being with other people.
*
1
2
3
4
5
16. I feel it is easy for me to make descisions.
*
1
2
3
4
5
17. I feel downtrodden.
*
1
2
3
4
5
18. I feel irritable.
*
1
2
3
4
5
19. I get upset easily.
*
1
2
3
4
5
20. I feel that i don't deserve to have a good time.
*
1
2
3
4
5
21. I feel that i have a full life.
*
1
2
3
4
5
22. I feel that people really care about me.
*
1
2
3
4
5
23. I have a great deal of fun.
*
1
2
3
4
5
24. I feel great in the morning.
*
1
2
3
4
5
25. I feel that my situation is hopeless.
*
1
2
3
4
5
Work Satisfaction (Contentment) Scales
The questions below deal with your characteristics, attitudes, and feelings as they relate to your present job. Read each one carefully and decide which of the choices best describes you.
1. Do you watch the clock ticking while you are working?
*
a. Constantly
b. At slack times
c. Never
2. When monday morning comes do you
*
a. Feel ready to go back to work?
b. Think longingly of being able to lie in the hospital with a broken leg?
c. Feel reluctant to start with, but fit into the work routine quite happily after an hour or so?
3. How do you feel at the end of a working day?
*
a. Dead tired and fit for nothing
b. Glad that you can start living
c. Sometimes tired, but usually pretty satisfied
4. Do you worry about your work?
*
a. Occasionally
b. Never
c. Often
5. Would you say that your job
*
a. Under uses your ability?
b. Overstrains your abilities?
c. Makes you do things you never thought you could do before?
6. Which statement is true for you?
*
a. I am rarely bored with my work
b. I am usually interested with my work, but there are patches of boredom
c. I am bored most of the time I am working
7. How much of your work time is spent making personal telephone calls, or with other matters not connected with the job?
*
a. Very little
b. Some, especially at crisis times in my personal life
c. Quite a bit
8. Do you daydream about having a different job?
*
a. Very little
b. Not a different job, but a better position in the same kind of job
c. Yes
9. Would you say that you feel
*
a. Pretty capable most of the time?
b. Sometimes capable?
c. Panicky and incapable most of the time?
10. Do you find that
*
a. You like and respect your colleagues?
b. You dislike your colleagues?
c. You are indifferent to your colleagues?
11. Which statement is most true for you?
*
a. I do not want to learn more about my work
b. I quite enjoyed learning my work when I first started
c. I like to go on learning as much as possible about my work
12. Which qualities do you think are your best points?
*
a. Sympathy
b. Clear-thinking
c. Calmness
d. Good memory
e. Concentration
f. Physical stamina
g. Inventiveness
h. Expertise
i. Charm
j. Humor
13. Now select the qualities that are demanded by your job.
*
a. Sympathy
b. Clear-thinking
c. Calmness
d. Good memory
e. Concentration
f. Physical stamina
g. Inventiveness
h. Expertise
i. Charm
j. Humor
14. Which statement do you most agree with?
*
a. A job is only a way to make enough money to keep yourself alive
b. A job is mainly a way of making money, but should be satisfying if possible
c. A job is a whole way of life
15. Do you work overtime?
*
a. Only when it is paid
b. Never
c. Often, even without pay
16. Have you ever been absent from work (other than for normal vacations or illness) in the last year?
*
a. Not at all
b. For a few days only
c. Often, even without pay
17. Would you rate yourself as
*
a. Very ambitious?
b. Unambitious?
c. Mildly ambitious?
18. Do you think that your colleagues
*
a. Like you, enjoy your company, and get on with you in general?
b. Dislike you?
c. Do not dislike you, but are not particularly friendly?
19. Do you talk about your work?
*
a. Only with your colleagues?
b. With friends and family?
c. Not if you can avoid it?
20. Do you suffer from minor unexplained illness and vague pains?
*
a. Seldom
b. Not too often
c. Frequently
21. How did you choose your current job?
*
a. Your parents or teachers decided for you
b. It was all you could find
c. It seemed the right thing for you
22. In a conflict between job and home, like an illness of a member of the family, who would win?
*
a. The family every time
b. The job every time
c. The family in a real emergency, but otherwise probably the job
23. Would you be happy to do the same job if it paid one third less?
*
a. Yes
b. You would like to, but could not afford to
c. No
24. If you were made redundant, which of these would you miss most?
*
a. The money
b. The work itself
c. The company of your colleagues
25. Would you take a day off to have fun?
*
a. Yes
b. No
c. Possibly, if there was nothing urgent for you to do at work
26. Do you feel unappreciated at work?
*
a. Occasionally
b. Often
c. Rarely
27. What do you dislike most about your job?
*
a. That your time is not your own
b. The boredom
c. That you cannot always do things the way that you want to
28. Do you keep your personal life separate from work? (Check with your partner on this one.)
*
a. Pretty strictly
b. Most of the time, but there is some overlap
c. Not at all
29. Would you advise a child of yours to take up the same kind of work as you do?
*
a. Yes, if he had the ability and temperament
b. No, you would warn him off
c. You would not press it, but you would not discourage him either
30. If you won or suddenly inherited a large sum of money, would you
*
a. Stop work for the rest of your life?
b. Take up some kind of work that you have always wanted to do?
c. Decide to continue, in some way, the same work you do now?
Filed Under:
Neuro Coaching Forms
