Home
SoundScience (SS+)
FAQ-SSPlus
Research & Articles
Contact Us
About Dr. Rodski & More
About Dr. Stan Rodski
Privacy Policy
Applied Research
Stress Scan Report – Neurocoach
Session Number
*
Coach Name
*
First
Last
Coachee Name
*
First
Last
Date Questionnaire Completed
*
DD slash MM slash YYYY
Number of hours sleep last night?
*
1. What was the quality of the sleep?
*
Please enter a number from
0
to
10
.
Poor <----> Excellent
0 1 2 3 4 5 6 7 8 9 10
2. Have you taken any medication today? YES/NO
*
If YES, what is it and what is it for?
3. Have you had any drinks today? eg. coffee, tea, hot chocolate, etc.
*
If YES, what...?
4. Right now do you have any pain?
*
No Pain <-> Extreme Pain
0 1 2 3 4 5 6 7 8 9 10
If YES, please describe.
5. Do you have any injuries? YES/NO
*
If YES, what are they?
6. Right now, what is your stress level?
*
No Stress <-> Very Stressed
0 1 2 3 4 5 6 7 8 9 10
If you are above 5, please explain.
7. Overall, how well (physically and mentally) do you feel?
*
Very Poor < - > Excellent
0 1 2 3 4 5 6 7 8 9 10
Relaxation
*
Activation
*
Overall
*
Comments
Filed Under:
Neuro Coaching Forms
RAIT(C) Post
Coachee Name
*
First
Last
Coach Name
First
Last
Company Name
*
Date Questionnaire Completed
*
DD slash MM slash YYYY
Email
*
How well did the program PERFORM with regard to...?
1
IMPORTANCE
10
Least
Most
1: We focus on future possibilities and not past mistakes
*
1
2
3
4
5
6
7
8
9
10
2: We tend to work on problems at the level at which they occur.
*
1
2
3
4
5
6
7
8
9
10
3: Our meetings have the time available to accomplish our agenda.
*
1
2
3
4
5
6
7
8
9
10
4: She/He provides and/or prescribes solutions
*
1
2
3
4
5
6
7
8
9
10
5: He/She recognizes that internal obstacles are often more daunting than external ones
*
1
2
3
4
5
6
7
8
9
10
6: Where we meet is comfortable and relaxed
*
1
2
3
4
5
6
7
8
9
10
7: The emphasis is on learning not instructing
*
1
2
3
4
5
6
7
8
9
10
8: Pro active coaching is used
*
1
2
3
4
5
6
7
8
9
10
9: Meeting venue allows me to concentrate
*
1
2
3
4
5
6
7
8
9
10
10: She/He is spontaneous and not time dependant
*
1
2
3
4
5
6
7
8
9
10
11: He/She see people in terms of their future potential, not just past performance
*
1
2
3
4
5
6
7
8
9
10
12: Our work together is supported with clear documentation
*
1
2
3
4
5
6
7
8
9
10
13: Builds awareness, responsibility and self belief as my goal
*
1
2
3
4
5
6
7
8
9
10
14: Building up my self esteem
*
1
2
3
4
5
6
7
8
9
10
15: Exercises and tasks between coaching sessions are valuable
*
1
2
3
4
5
6
7
8
9
10
16: Encourages me to make decisions to take successful actions
*
1
2
3
4
5
6
7
8
9
10
17: She/He helped me recognize my full responsibilities
*
1
2
3
4
5
6
7
8
9
10
18: Meeting location
*
1
2
3
4
5
6
7
8
9
10
19: Facilitated my self awareness
*
1
2
3
4
5
6
7
8
9
10
20: Encouraged me to take on further responsibility
*
1
2
3
4
5
6
7
8
9
10
21: Pace of learning
*
1
2
3
4
5
6
7
8
9
10
22: Quality feedback and input was given
*
1
2
3
4
5
6
7
8
9
10
23: My self motivation was helped
*
1
2
3
4
5
6
7
8
9
10
24: Quality of handouts, materials, notes provided, etc.
*
1
2
3
4
5
6
7
8
9
10
25: My choices were made clear
*
1
2
3
4
5
6
7
8
9
10
26: He/She provoked proactive and focused thought
*
1
2
3
4
5
6
7
8
9
10
27: Frequency of coaching meetings
*
1
2
3
4
5
6
7
8
9
10
28: She/He focused on my attention and observation capabilities
*
1
2
3
4
5
6
7
8
9
10
29: He/She helps me eliminate obstacles (internal and external) to achieve my goals
*
1
2
3
4
5
6
7
8
9
10
30: Timing of Coaching Messages
*
1
2
3
4
5
6
7
8
9
10
Comments
Filed Under:
Neuro Coaching Forms
RAIT(C) Pre
Coachee Name
*
First
Last
Coach Name
First
Last
Company Name
*
Date Questionnaire Completed
*
DD slash MM slash YYYY
dd/mm/yyyy
Phone Number
*
Include country code if known
Country
*
Email
*
How IMPORTANT to you is ...?
1
IMPORTANCE
10
Least
Most
1: We focus on future possibilities and not past mistakes
*
1
2
3
4
5
6
7
8
9
10
2: We tend to work on problems at the level at which they occur.
*
1
2
3
4
5
6
7
8
9
10
3: Our meetings have the time available to accomplish our agenda.
*
1
2
3
4
5
6
7
8
9
10
4: She/He provides and/or prescribes solutions
*
1
2
3
4
5
6
7
8
9
10
5: He/She recognizes that internal obstacles are often more daunting than external ones
*
1
2
3
4
5
6
7
8
9
10
6: Where we meet is comfortable and relaxed
*
1
2
3
4
5
6
7
8
9
10
7: The emphasis is on learning not instructing
*
1
2
3
4
5
6
7
8
9
10
8: Pro active coaching is used
*
1
2
3
4
5
6
7
8
9
10
9: Meeting venue allows me to concentrate
*
1
2
3
4
5
6
7
8
9
10
10: She/He is spontaneous and not time dependant
*
1
2
3
4
5
6
7
8
9
10
11: He/She see people in terms of their future potential, not just past performance
*
1
2
3
4
5
6
7
8
9
10
12: Our work together is supported with clear documentation
*
1
2
3
4
5
6
7
8
9
10
13: Builds awareness, responsibility and self belief as my goal
*
1
2
3
4
5
6
7
8
9
10
14: Building up my self esteem
*
1
2
3
4
5
6
7
8
9
10
15: Exercises and tasks between coaching sessions are valuable
*
1
2
3
4
5
6
7
8
9
10
16: Encourages me to make decisions to take successful actions
*
1
2
3
4
5
6
7
8
9
10
17: She/He helped me recognize my full responsibilities
*
1
2
3
4
5
6
7
8
9
10
18: Meeting location
*
1
2
3
4
5
6
7
8
9
10
19: Facilitated my self awareness
*
1
2
3
4
5
6
7
8
9
10
20: Encouraged me to take on further responsibility
*
1
2
3
4
5
6
7
8
9
10
21: Pace of learning
*
1
2
3
4
5
6
7
8
9
10
22: Quality feedback and input was given
*
1
2
3
4
5
6
7
8
9
10
23: My self motivation was helped
*
1
2
3
4
5
6
7
8
9
10
24: Quality of handouts, materials, notes provided, etc.
*
1
2
3
4
5
6
7
8
9
10
25: My choices were made clear
*
1
2
3
4
5
6
7
8
9
10
26: He/She provoked proactive and focused thought
*
1
2
3
4
5
6
7
8
9
10
27: Frequency of coaching meetings
*
1
2
3
4
5
6
7
8
9
10
28: She/He focused on my attention and observation capabilities
*
1
2
3
4
5
6
7
8
9
10
29: He/She helps me eliminate obstacles (internal and external) to achieve my goals
*
1
2
3
4
5
6
7
8
9
10
30: Timing of Coaching Messages
*
1
2
3
4
5
6
7
8
9
10
Filed Under:
Neuro Coaching Forms
Performance
Coach Name
First
Last
Client Name
First
Last
Date of Testing
DD slash MM slash YYYY
Check any attributes you are REALLY GOOD at.
Attributes
Comfortable working alone
Appreciating your own appearance
Being assertive
Communicating effectively
Handling complaints
Maintaining confidence
Projecting confidence
Giving constructive criticism
Paying attention to detail
Dealing with disappointment
Maintaining enthusiasm
Focusing attention
Follow through
Following up
Setting and meeting goals
Handling objections
Keeping a sense of humour
Expressing leadership skills
Listening actively and attentively
Leading meetings
Handling multiple tasks
Holding to objectives
Maintaining comfort with people
Planning long range strategies
Seeing other points of view
Maintaining positive energy
Setting priorities
Problem solving
Remembering product knowledge
Public speaking
Answering questions
Meeting quotas
Developing rapport
Handling rejection
Managing resources
Delegating responsibility
Taking responsibility
Staying on schedule
Accessing positive self-concept
Maintaining self control
Setting limits
Speaking clearly
Staying calm
Using tact
Working as part of a team
Team building
Holding to values
Maintaining versatility
Step 2
Please return to the list above and pick out your top five attributes, unchecking all others.
Step 3
Please rank the selected top 5 [From Highest:1 to Lowest:5]
1:
Attributes
Comfortable working alone
Appreciating your own appearance
Being assertive
Communicating effectively
Handling complaints
Maintaining confidence
Projecting confidence
Giving constructive criticism
Paying attention to detail
Dealing with disappointment
Maintaining enthusiasm
Focusing attention
Follow through
Following up
Setting and meeting goals
Handling objections
Keeping a sense of humour
Expressing leadership skills
Listening actively and attentively
Leading meetings
Handling multiple tasks
Holding to objectives
Maintaining comfort with people
Planning long range strategies
Seeing other points of view
Maintaining positive energy
Setting priorities
Problem solving
Remembering product knowledge
Public speaking
Answering questions
Meeting quotas
Developing rapport
Handling rejection
Managing resources
Delegating responsibility
Taking responsibility
Staying on schedule
Accessing positive self-concept
Maintaining self control
Setting limits
Speaking clearly
Staying calm
Using tact
Working as part of a team
Team building
Holding to values
Maintaining versatility
2:
Attributes
Comfortable working alone
Appreciating your own appearance
Being assertive
Communicating effectively
Handling complaints
Maintaining confidence
Projecting confidence
Giving constructive criticism
Paying attention to detail
Dealing with disappointment
Maintaining enthusiasm
Focusing attention
Follow through
Following up
Setting and meeting goals
Handling objections
Keeping a sense of humour
Expressing leadership skills
Listening actively and attentively
Leading meetings
Handling multiple tasks
Holding to objectives
Maintaining comfort with people
Planning long range strategies
Seeing other points of view
Maintaining positive energy
Setting priorities
Problem solving
Remembering product knowledge
Public speaking
Answering questions
Meeting quotas
Developing rapport
Handling rejection
Managing resources
Delegating responsibility
Taking responsibility
Staying on schedule
Accessing positive self-concept
Maintaining self control
Setting limits
Speaking clearly
Staying calm
Using tact
Working as part of a team
Team building
Holding to values
Maintaining versatility
3:
Attributes
Comfortable working alone
Appreciating your own appearance
Being assertive
Communicating effectively
Handling complaints
Maintaining confidence
Projecting confidence
Giving constructive criticism
Paying attention to detail
Dealing with disappointment
Maintaining enthusiasm
Focusing attention
Follow through
Following up
Setting and meeting goals
Handling objections
Keeping a sense of humour
Expressing leadership skills
Listening actively and attentively
Leading meetings
Handling multiple tasks
Holding to objectives
Maintaining comfort with people
Planning long range strategies
Seeing other points of view
Maintaining positive energy
Setting priorities
Problem solving
Remembering product knowledge
Public speaking
Answering questions
Meeting quotas
Developing rapport
Handling rejection
Managing resources
Delegating responsibility
Taking responsibility
Staying on schedule
Accessing positive self-concept
Maintaining self control
Setting limits
Speaking clearly
Staying calm
Using tact
Working as part of a team
Team building
Holding to values
Maintaining versatility
4:
Attributes
Comfortable working alone
Appreciating your own appearance
Being assertive
Communicating effectively
Handling complaints
Maintaining confidence
Projecting confidence
Giving constructive criticism
Paying attention to detail
Dealing with disappointment
Maintaining enthusiasm
Focusing attention
Follow through
Following up
Setting and meeting goals
Handling objections
Keeping a sense of humour
Expressing leadership skills
Listening actively and attentively
Leading meetings
Handling multiple tasks
Holding to objectives
Maintaining comfort with people
Planning long range strategies
Seeing other points of view
Maintaining positive energy
Setting priorities
Problem solving
Remembering product knowledge
Public speaking
Answering questions
Meeting quotas
Developing rapport
Handling rejection
Managing resources
Delegating responsibility
Taking responsibility
Staying on schedule
Accessing positive self-concept
Maintaining self control
Setting limits
Speaking clearly
Staying calm
Using tact
Working as part of a team
Team building
Holding to values
Maintaining versatility
5:
Attributes
Comfortable working alone
Appreciating your own appearance
Being assertive
Communicating effectively
Handling complaints
Maintaining confidence
Projecting confidence
Giving constructive criticism
Paying attention to detail
Dealing with disappointment
Maintaining enthusiasm
Focusing attention
Follow through
Following up
Setting and meeting goals
Handling objections
Keeping a sense of humour
Expressing leadership skills
Listening actively and attentively
Leading meetings
Handling multiple tasks
Holding to objectives
Maintaining comfort with people
Planning long range strategies
Seeing other points of view
Maintaining positive energy
Setting priorities
Problem solving
Remembering product knowledge
Public speaking
Answering questions
Meeting quotas
Developing rapport
Handling rejection
Managing resources
Delegating responsibility
Taking responsibility
Staying on schedule
Accessing positive self-concept
Maintaining self control
Setting limits
Speaking clearly
Staying calm
Using tact
Working as part of a team
Team building
Holding to values
Maintaining versatility
Filed Under:
Neuro Coaching Forms
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
RAIT(T) Pre
Trainer Name (If Known)
First
Last
Your Name
*
First
Last
Program Name
*
Company Name
*
Date Questionnaire Completed
*
DD slash MM slash YYYY
dd/mm/yyyy
Phone Number
Include country code if known
Country
*
Email
*
How IMPORTANT to you is ...?
1
IMPORTANCE
10
Least
Most
1: My company believes in this sort of training
*
1
2
3
4
5
6
7
8
9
10
2: Understanding how this training will impact my company
*
1
2
3
4
5
6
7
8
9
10
3: The comfort of the seating
*
1
2
3
4
5
6
7
8
9
10
4: What I have learnt is transferable into my organisation
*
1
2
3
4
5
6
7
8
9
10
5: Concepts are able to be communicated by the trainer
*
1
2
3
4
5
6
7
8
9
10
6: The lighting in the room
*
1
2
3
4
5
6
7
8
9
10
7: I know what is expected of me back at work as a result of this training
*
1
2
3
4
5
6
7
8
9
10
8: Stimulating content
*
1
2
3
4
5
6
7
8
9
10
9: The ambience (overall feeling) of the training room
*
1
2
3
4
5
6
7
8
9
10
10: Presentation style of the trainer
*
1
2
3
4
5
6
7
8
9
10
11: The training being valuable to me
*
1
2
3
4
5
6
7
8
9
10
12: Clarity of presentations, handouts, all things read
*
1
2
3
4
5
6
7
8
9
10
13: Being encouraged to participate during the training
*
1
2
3
4
5
6
7
8
9
10
14: Integration of humour
*
1
2
3
4
5
6
7
8
9
10
15: Pace of learning
*
1
2
3
4
5
6
7
8
9
10
16: Trainer’s ability to hold my interest
*
1
2
3
4
5
6
7
8
9
10
17: Trainer able to build trust during the program
*
1
2
3
4
5
6
7
8
9
10
18: Noise / Quiet levels in the training room
*
1
2
3
4
5
6
7
8
9
10
19: Trainer displays clear understanding
*
1
2
3
4
5
6
7
8
9
10
20: Feeling involved during the program
*
1
2
3
4
5
6
7
8
9
10
21: Quality of training facilities
*
1
2
3
4
5
6
7
8
9
10
22: Trainer's knowledge of subject and materials
*
1
2
3
4
5
6
7
8
9
10
23: Key learnings being taken in and sticking
*
1
2
3
4
5
6
7
8
9
10
24: Training format, e.g. 1 full day versus 2 half days, etc.
*
1
2
3
4
5
6
7
8
9
10
25: Trainer provides support during program
*
1
2
3
4
5
6
7
8
9
10
26: Trainer uses active listening / questioning and exploration
*
1
2
3
4
5
6
7
8
9
10
27: Time in program to practice learnings
*
1
2
3
4
5
6
7
8
9
10
28: Maintaining your understanding during the program
*
1
2
3
4
5
6
7
8
9
10
29: Coming away from the program with new knowledge and understanding
*
1
2
3
4
5
6
7
8
9
10
30: Temperature of training room
*
1
2
3
4
5
6
7
8
9
10
Filed Under:
Neuro Coaching Forms
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
Stress Scan Report
Session Number
*
Coach Name
*
First
Last
Coachee Name
*
First
Last
Date of testing
*
DD slash MM slash YYYY
Number of hours sleep last night?
*
1. What was the quality of the sleep?
*
Please enter a number from
0
to
10
.
Poor <----> Excellent
0 1 2 3 4 5 6 7 8 9 10
2. Have you taken any medication today? YES/NO
*
If YES, what is it and what is it for?
3. Have you had any drinks today? e.g. coffee, tea, hot chocolate, etc.
*
If YES, what...?
4. Right now do you have any pain?
*
No Pain <-> Extreme Pain
0 1 2 3 4 5 6 7 8 9 10
If YES, please describe
5. Do you have any injuries? YES/NO
*
If YES, what are they?
6. Right now, what is your stress level?
*
No Stress <-> Very Stressed
0 1 2 3 4 5 6 7 8 9 10
If you are above 5, please explain.
7. Overall, how well (physically and mentally) do you feel?
*
Very Poor < - > Excellent
0 1 2 3 4 5 6 7 8 9 10
Relaxation
*
Activation
*
Overall
*
9. Key Observations if any
Filed Under:
Neuro Coaching Forms
RAIT(T) Post
Trainer Name
*
First
Last
Your Name
*
First
Last
Company Name
*
Date Questionnaire Completed
*
DD slash MM slash YYYY
Email
*
How well did the program PERFORM with regard to...?
IMPORTANCE
Least
Most
1: My company believes in this sort of training
*
1
2
3
4
5
6
7
8
9
10
2: Understanding how this training will impact my company
*
1
2
3
4
5
6
7
8
9
10
3: The comfort of the seating
*
1
2
3
4
5
6
7
8
9
10
4: What I have learnt is transferable into my organisation
*
1
2
3
4
5
6
7
8
9
10
5: Concepts are able to be communicated by the trainer
*
1
2
3
4
5
6
7
8
9
10
6: The lighting in the room
*
1
2
3
4
5
6
7
8
9
10
7: I know what is expected of me back at work as a result of this training
*
1
2
3
4
5
6
7
8
9
10
8: Stimulating content
*
1
2
3
4
5
6
7
8
9
10
9: The ambience (overall feeling) of the training room
*
1
2
3
4
5
6
7
8
9
10
10: Presentation style of the trainer
*
1
2
3
4
5
6
7
8
9
10
11: The training being valuable to me
*
1
2
3
4
5
6
7
8
9
10
12: Clarity of presentations, handouts, all things read
*
1
2
3
4
5
6
7
8
9
10
13: Being encouraged to participate during the training
*
1
2
3
4
5
6
7
8
9
10
14: Integration of humour
*
1
2
3
4
5
6
7
8
9
10
15: Pace of learning
*
1
2
3
4
5
6
7
8
9
10
16: Trainer’s ability to hold my interest
*
1
2
3
4
5
6
7
8
9
10
17: Trainer able to build trust during the program
*
1
2
3
4
5
6
7
8
9
10
18: Noise / Quiet levels in the training room
*
1
2
3
4
5
6
7
8
9
10
19: Trainer displays clear understanding
*
1
2
3
4
5
6
7
8
9
10
20: Feeling involved during the program
*
1
2
3
4
5
6
7
8
9
10
21: Quality of training facilities
*
1
2
3
4
5
6
7
8
9
10
22: Trainer's knowledge of subject and materials
*
1
2
3
4
5
6
7
8
9
10
23: Key learnings being taken in and sticking
*
1
2
3
4
5
6
7
8
9
10
24: Training format, e.g. 1 full day versus 2 half days, etc.
*
1
2
3
4
5
6
7
8
9
10
25: Trainer provides support during program
*
1
2
3
4
5
6
7
8
9
10
26: Trainer uses active listening / questioning and exploration
*
1
2
3
4
5
6
7
8
9
10
27: Time in program to practice learnings
*
1
2
3
4
5
6
7
8
9
10
28: Maintaining your understanding during the program
*
1
2
3
4
5
6
7
8
9
10
29: Coming away from the program with new knowledge and understanding
*
1
2
3
4
5
6
7
8
9
10
30: Temperature of training room
*
1
2
3
4
5
6
7
8
9
10
Comments
Filed Under:
Neuro Coaching Forms
RAIT(C) Pre: ANZ
Organisation
*
Manager/Coach Name
*
First
Last
Line Manager Name
*
First
Last
Coachee Name
*
First
Last
Coach Location
*
Coachee Location
*
Date Questionnaire Completed
*
DD slash MM slash YYYY
Phone Number
*
Include country code if known
Country
*
Email
*
How IMPORTANT to you is ...?
Please use 10 sparingly.
1
IMPORTANCE
10
Least
Most
1: We focus on future possibilities and not past mistakes
*
1
2
3
4
5
6
7
8
9
10
2: We tend to work on problems at the level at which they occur.
*
1
2
3
4
5
6
7
8
9
10
3: Our meetings have the time available to accomplish our agenda.
*
1
2
3
4
5
6
7
8
9
10
4: She/He provides and/or prescribes solutions
*
1
2
3
4
5
6
7
8
9
10
5: He/She recognizes that internal obstacles are often more daunting than external ones
*
1
2
3
4
5
6
7
8
9
10
6: Where we meet is comfortable and relaxed
*
1
2
3
4
5
6
7
8
9
10
7: The emphasis is on learning not instructing
*
1
2
3
4
5
6
7
8
9
10
8: Pro active coaching is used
*
1
2
3
4
5
6
7
8
9
10
9: Meeting venue allows me to concentrate
*
1
2
3
4
5
6
7
8
9
10
10: She/He is spontaneous and not time dependant
*
1
2
3
4
5
6
7
8
9
10
11: He/She see people in terms of their future potential, not just past performance
*
1
2
3
4
5
6
7
8
9
10
12: Our work together is supported with clear documentation
*
1
2
3
4
5
6
7
8
9
10
13: Builds awareness, responsibility and self belief as my goal
*
1
2
3
4
5
6
7
8
9
10
14: Building up my self esteem
*
1
2
3
4
5
6
7
8
9
10
15: Exercises and tasks between coaching sessions are valuable
*
1
2
3
4
5
6
7
8
9
10
16: Encourages me to make decisions to take successful actions
*
1
2
3
4
5
6
7
8
9
10
17: She/He helped me recognize my full responsibilities
*
1
2
3
4
5
6
7
8
9
10
18: Meeting location
*
1
2
3
4
5
6
7
8
9
10
19: Facilitated my self awareness
*
1
2
3
4
5
6
7
8
9
10
20: Encouraged me to take on further responsibility
*
1
2
3
4
5
6
7
8
9
10
21: Pace of learning
*
1
2
3
4
5
6
7
8
9
10
22: Quality feedback and input was given
*
1
2
3
4
5
6
7
8
9
10
23: My self motivation was helped
*
1
2
3
4
5
6
7
8
9
10
24: Quality of handouts, materials, notes provided, etc.
*
1
2
3
4
5
6
7
8
9
10
25: My choices were made clear
*
1
2
3
4
5
6
7
8
9
10
26: He/She provoked proactive and focused thought
*
1
2
3
4
5
6
7
8
9
10
27: Frequency of coaching meetings
*
1
2
3
4
5
6
7
8
9
10
28: She/He focused on my attention and observation capabilities
*
1
2
3
4
5
6
7
8
9
10
29: He/She helps me eliminate obstacles (internal and external) to achieve my goals
*
1
2
3
4
5
6
7
8
9
10
30: Timing of Coaching Messages
*
1
2
3
4
5
6
7
8
9
10
Filed Under:
Neuro Coaching Forms
Next Page »
