MEFS qEEG BRAIN MAPPreview Intake FormADULT CEC 18 and olderEstimated time: 3 minutesField is required!Field is required!Field is required!Field is required!Field is required!Field is required!All fields are requiredI have trouble filtering out background noises.NoneMildModerateSevereField is required!Field is required!I find it difficult to add numbers in my head.NoneMildModerateSevereField is required!Field is required!I forget what I (did) had to eat the day before.NoneMildModerateSevereField is required!Field is required!I have difficulty remembering a phone number long enough to dial it.NoneMildModerateSevereField is required!Field is required!I have trouble remembering names.NoneMildModerateSevereField is required!Field is required!I find myself wandering while in conversation.NoneMildModerateSevereField is required!Field is required!I have difficulty paying attention to a boring presentation.NoneMildModerateSevereField is required!Field is required!I have a short attention span.NoneMildModerateSevereField is required!Field is required!I rigidly stick to the same solution.NoneMildModerateSevereField is required!Field is required!I have difficulty with multitasking.NoneMildModerateSevereField is required!Field is required!I am easily distracted.NoneMildModerateSevereField is required!Field is required!I find myself frequently saying things that shock others.NoneMildModerateSevereField is required!Field is required!I have trouble controlling my emotions.NoneMildModerateSevereField is required!Field is required!I often blurt out things I later regret.NoneMildModerateSevereField is required!Field is required!I have to re-read a paragraph several times before it sinks in.NoneMildModerateSevereField is required!Field is required!I have uncontrollable episodes of anger.NoneMildModerateSevereField is required!Field is required!I get stuck on ideas, thoughts or behaviors.NoneMildModerateSevereField is required!Field is required!I have trouble finding my car in the parking lot.NoneMildModerateSevereField is required!Field is required!I get lost easily in buildings or malls.NoneMildModerateSevereField is required!Field is required!I feel aware of everything going on around me all the time.NoneMildModerateSevereField is required!Field is required!I ruminate over my To Do list constantly.NoneMildModerateSevereField is required!Field is required!I worry constantly.NoneMildModerateSevereField is required!Field is required!I have panic attacks.NoneMildModerateSevereField is required!Field is required!I feel depressed.NoneMildModerateSevereField is required!Field is required!I feel disorganized all the time.NoneMildModerateSevereField is required!Field is required!I feel generally unmotivated and apathetic.NoneMildModerateSevereField is required!Field is required!I have insomnia.NoneMildModerateSevereField is required!Field is required!I reverse letters (dyslexia).NoneMildModerateSevereField is required!Field is required!I have trouble doing math.NoneMildModerateSevereField is required!Field is required!I have a sensitivity to light and noises.NoneMildModerateSevereField is required!Field is required!I have poor handwriting.NoneMildModerateSevereField is required!Field is required!I feel spacey or out of my body.NoneMildModerateSevereField is required!Field is required!I have trouble reading people's faces correctly.NoneMildModerateSevereField is required!Field is required!I feel restless or agitated.NoneMildModerateSevereField is required!Field is required!I feel manic.NoneMildModerateSevereField is required!Field is required!I think obsessively.NoneMildModerateSevereField is required!Field is required!I feel like a victim.NoneMildModerateSevereField is required!Field is required!I have trouble shifting my attention.NoneMildModerateSevereField is required!Field is required!I have difficulty organizing information.NoneMildModerateSevereField is required!Field is required!I have difficulty recognizing peoples faces.NoneMildModerateSevereField is required!Field is required!I speak in monotone.NoneMildModerateSevereField is required!Field is required!I have trouble remembering the sequence of past events.NoneMildModerateSevereField is required!Field is required!I have difficulty with categorization.NoneMildModerateSevereField is required!Field is required!I have difficulty focusing on an idea.NoneMildModerateSevereField is required!Field is required!I talk constantly.NoneMildModerateSevereField is required!Field is required!I feel like I am on an emotional rollercoaster.NoneMildModerateSevereField is required!Field is required!I have to frequently develop special strategies to get my way.NoneMildModerateSevereField is required!Field is required!I feel constantly tired.NoneMildModerateSevereField is required!Field is required!SendUnlock your Edge Now
