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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