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Applied Research
Neurobics for the brain – “5 Brain”
Step
1
of
5
20%
Note: Please allow at least 15 minutes to complete the following forms.
Your Name
*
First
Last
Company/School/Other
*
Date Questionnaire Completed
*
DD slash MM slash YYYY
Email
The Basil Ganglia System Measurement
BRAIN KNOTS Cause:
Anxiety, panic attacks, muscle tension, tremors, fine motor problems and headaches
How often have you experienced the factors below?
0 = Never
1 = Rarely
2 = Occasional
3 = Frequently
4 = Very Frequently
Panic Attacks
*
0
1
2
3
4
Excessive Motivation
*
0
1
2
3
4
Tics
*
0
1
2
3
4
Quick startle reaction
*
0
1
2
3
4
Shyness
*
0
1
2
3
4
Conflict avoidance
*
0
1
2
3
4
Predict the worst
*
0
1
2
3
4
Fear of doing something crazy
*
0
1
2
3
4
Persistent phobias
*
0
1
2
3
4
Low Motivation
*
0
1
2
3
4
Poor handwriting
*
0
1
2
3
4
At times trouble breathing
*
0
1
2
3
4
Easily embarrassed
*
0
1
2
3
4
At times feeling dizzy and faint
*
0
1
2
3
4
Can freeze when anxious
*
0
1
2
3
4
At times feel nauseas
*
0
1
2
3
4
Hot and cold flushes, sweating
*
0
1
2
3
4
Worry about what others are thinking
*
0
1
2
3
4
Feel judged and scrutinised by others
*
0
1
2
3
4
Feel nervous and anxious
*
0
1
2
3
4
Heart appears to pump rapidly
*
0
1
2
3
4
Headache, sore muscles and tremors
*
0
1
2
3
4
Controls
Anxiety
Fear
Body Movement
Speed
Deep Limbic System Measurement
Brain Knots cause:
Moodiness, negative thinking, appetite and sleep problems, decreased motivation and decreased sexual appetite
How often have you experienced the factors below?
0 = Never
1 = Rarely
2 = Occasional
3 = Frequently
4 = Very Frequently
Low energy
*
0
1
2
3
4
Crying
*
0
1
2
3
4
Moodiness
*
0
1
2
3
4
Feel very little joy
*
0
1
2
3
4
Appetite Changes
*
0
1
2
3
4
Feeling Dissatisfied
*
0
1
2
3
4
Feel helpless
*
0
1
2
3
4
Feel sad
*
0
1
2
3
4
Excessive guilt
*
0
1
2
3
4
Lowered interest in having fun
*
0
1
2
3
4
Sleep changes
*
0
1
2
3
4
Irritability
*
0
1
2
3
4
Negativity
*
0
1
2
3
4
Decreased interest in others
*
0
1
2
3
4
Feel hopeless about the future
*
0
1
2
3
4
Poor concentration
*
0
1
2
3
4
Low self esteem
*
0
1
2
3
4
Forgetful
*
0
1
2
3
4
Negative sensitivity to smell
*
0
1
2
3
4
Decreased interest in physical activity
*
0
1
2
3
4
CONTROLS
emotions
motivation
appetite
sleep
libido
The Pre Frontal Cortex System Measurement
BRAIN KNOT Causes:
Short attention span, distractibility, lack of perseverance, impulse control problems, hyperactivity, poor time management, disorganisation, procrastination, poor judgement, short term memory problems and social anxiety
How often have you experienced the factors below?
0 = Never
1 = Rarely
2 = Occasional
3 = Frequently
4 = Very Frequently
Poor planning skills
*
0
1
2
3
4
Trouble sustaining attention
*
0
1
2
3
4
Poor organisation of time and space
*
0
1
2
3
4
Difficulties expressing feelings
*
0
1
2
3
4
Lethargy
*
0
1
2
3
4
Difficulty waiting your turn
*
0
1
2
3
4
Conflict Seeking
*
0
1
2
3
4
Difficulty expressing empathy
*
0
1
2
3
4
Boredom
*
0
1
2
3
4
Trouble listening
*
0
1
2
3
4
Excessive daydreams
*
0
1
2
3
4
Talking too much or too little
*
0
1
2
3
4
Distractibility
*
0
1
2
3
4
Can't give close attention to details
*
0
1
2
3
4
Lack of clear goals
*
0
1
2
3
4
Trouble learning from experience
*
0
1
2
3
4
Difficult to remain seated as required
*
0
1
2
3
4
Feel like you are in a fog
*
0
1
2
3
4
Lack of motivation
*
0
1
2
3
4
Blurt out answers too quickly
*
0
1
2
3
4
Say or do without thinking
*
0
1
2
3
4
Restlessness
*
0
1
2
3
4
Butting into conversations
*
0
1
2
3
4
Poor follow through
*
0
1
2
3
4
CONTROLS
attention
perseverance
judgement
impulse control
organisation
problem solving
thinking
empathy
The Cingulate System Measurement
BRAIN KNOT Causes:
worrying, obsessions,compulsions,argumentativeness,thinking,insensitivity,addiction,inflexibility, obsessive compulsive
How often have you experienced the factors below?
0 = Never
1 = Rarely
2 = Occasional
3 = Frequently
4 = Very Frequently
Intense dislike of change
*
0
1
2
3
4
Repetitive negative thoughts
*
0
1
2
3
4
Upset when things are out of place
*
0
1
2
3
4
Difficult to see options
*
0
1
2
3
4
Senseless worrying
*
0
1
2
3
4
Hold grudges
*
0
1
2
3
4
Compulsive behaviours
*
0
1
2
3
4
Argumentative
*
0
1
2
3
4
Upset by things not going your way
*
0
1
2
3
4
Don't listen to others - unchangeable
*
0
1
2
3
4
Very upset when things don't go your way
*
0
1
2
3
4
Predict negative outcomes
*
0
1
2
3
4
Say no without thinking
*
0
1
2
3
4
Take a course of action regardless of whether it is good
*
0
1
2
3
4
Other people think you worry too much
*
0
1
2
3
4
Controls
adaptability
thinking
flexibility
able to see options
cooperation
attention shifts
The Temporal Lobes System Assessment
BRAIN KNOT Causes:
Left -
side of brain: aggression, dark thoughts, emotional stability
Right -
side of brain: social skills problems
Both -
memory problems, heartache, déjà vu, confusion and seizures.
How often have you experienced the factors below?
0 = Never
1 = Rarely
2 = Occasional
3 = Frequently
4 = Very Frequently
Forgetfulness
*
0
1
2
3
4
Irritability that builds up
*
0
1
2
3
4
Panic/fear that tends to builds up
*
0
1
2
3
4
Sensitive/mildly paranoid
*
0
1
2
3
4
Headache/abdominal pain(no origin)
*
0
1
2
3
4
Rage with no provocation
*
0
1
2
3
4
Misinterpret comments as negative
*
0
1
2
3
4
Memory problems
*
0
1
2
3
4
Reading problems
*
0
1
2
3
4
See shadows or hear muffled sounds
*
0
1
2
3
4
Often have a sense of déjà vu
*
0
1
2
3
4
Short fuse/very irritable
*
0
1
2
3
4
Family history of explosiveness
*
0
1
2
3
4
Intense negative thoughts
*
0
1
2
3
4
Periods of forgetfulness
*
0
1
2
3
4
Confused at times
*
0
1
2
3
4
Controls
LEFT
language
memory
learning
complex memories
emotional stability
RIGHT
facial expressions
vocal iteration
rhythm
music
visual learning
Filed Under:
Neuro Coaching Forms
