Adult Assessment Form 2 of 4

Client's Name *

First Name

Last Name

Motor Characteristics of Right Brain Delay

You have poor coordination. You are clumsy with odd posture and gait

You have difficulty coordinating both sides of your body, such as in running, walking or swimming

You have poor muscle tone. Your muscles are flabby or floppy instead of taut

You are very flexible, or even double jointed

You have and may have recently acquired facial tics or make repetitive and involuntary vocal sounds, such as clearing the throat

You have repetitive motor mannerisms, such as twisting or playing with your hair or pulling on your sleeves

You have a tendency to walk on your toes

You do not have good balance or notice it has recently gotten worse

You have chronic tendonitis, patella tendonitis, carpal tunnel syndrome, or have/had trouble with your rotator cuff or tennis elbow on the right side of your body

You get a tremor or eye twitch on the right side of your body

You cannot cross your eyes

You have poor depth perception. e.g. You have trouble judging distances or driving

Motor Characteristics of Left Brain Delay *

You have difficulty performing fine motor skills such as buttoning a shirt and doing small detail work with hands

You have poor handwriting or handwriting that is hard to read

Have difficulty planning a sequence of coordinated movements, such as dance steps or certain sports activities

You have a twitch in your right eye but not your left

You frequently have problems with writer's cramp

You stumble over words in your speech when you are tired

You are not musically inclined e.g. you have found it difficult to play a musical instrument

You have chronic tendonitis, patella tendonitis, carpal tunnel syndrome or have/had rotator cuff problems or tennis elbow on the left side of your body

You get tremors on the right side of your body

You find it difficult to imitate an action without actually doing it e.g. you can't mimic how to strike a match without using a pack of matches

You're ambidextrous. You don't really favour your right or left hand

Sensory Characteristics of a Right Brain Delay *

Poor Spatial orientation - bumps into things often

You are hypersensitive to sound e.g. you hate loud noises, such as fireworks and are especially bothered by high pitched sounds, such as children screaming or scratching a chalkboard

You generally feel disconnected from your body

You compulsively touch things e.g. you'll touch fabric when passing through an aisle in a store even though you are not interested in buying, or you rub your hands over furniture for no particular reason when you are in someone else's home

You don't like the feel of clothing on your arms or legs e.g. you will wear shorts or will pull off clothes at every chance you get

You don't like being touched or when people get in your personal space

You have a poor sense of smell e.g. don't particularly notice when there is a wood fire burning, popcorn popping or biscuits being baked in the oven

You have an inability to recognise or differentiate between sounds or musical notes. You may have been told that you have a "tin ear" or you sing off key

You have experienced hearing voices when no one is there or hear a ringing in your right ear

You smell unusual scents others don't smell or when none exists

You get a metallic or unpleasant taste in your mouth for no discernible reason e.g. like when you take medications

You are obsessed with religion or understanding the meaning of life, beyond what many would consider normal. You are always quoting scripture in almost every conversation or facebook post.

You have unexplained lapses in time, you don't lose consciousness, but you can't remember certain periods of time

Your right eye is chronically irritated or red

Hearing in your left ear is more difficult that in your right

You seem to lose your perception of time, or you always had a poor sense of timing e.g. you over/under estimate how much time something will take

Sensory Characteristics of a Left Brain delay *

You have to think twice when distinguishing Left from Right

You or others feel you do not hear well, even though hearing tests have come out normal

You easily get motion sickness

You are very sensitive to movement e.g. you can't ride in a car and read at the same time

The smallest things can make you nauseated e.g. the sight of blood or certain unpleasant smells

You feel you don't hear as well with your right ear as you do with your left

Your left eye is chronically irritated, dry or red

Emotional Characteristics of a Right Brain Delay *

You are or appear to others to be overly happy and affectionate e.g. you love to hug and kiss others, such as your kids, friends and pets

Your behaviour could be described as manic, you can burst into tears or laughter almost spontaneously

You have sudden outbursts of anger and fear

You occasionally experience panic and/or anxiety attacks

You sometimes have dark/ violent thoughts

You hold on to past "hurts", you just can't let go

Your face normally lacks expression and you don't exhibit much body language when interacting with others

You're too uptight, you can't seem to loosen up

You are not very empathetic or do not appear to be to others

You don't show emotion in situations the same as others do

You like taking risks and are known as a risk taker

Normally, you speak in a monotone and have no expression in your voice

You don't like being in social situations. Others would call you anti-social

You don't generally ever feel "afraid" or seem to experience fear

Emotional Characteristics of a Left Brain delay *

You get frightened very easily

You frequently and easily get depressed or feel down in the dumps

You worry a lot and are considered a worry wart by those who know you best

You have had or think you have had post traumatic stress disorder (PTSD)

You have a lot of fears and phobias

You frequently get moody and irritable

You contemplate suicide

You lack motivation

You don't get pleasure out of life, food or anything in particular

Others would say it is hard to make you happy

You get insulted easily

You frequently feel overwhelmed by the tasks at hand and what's going on in the world around you

You can feel another's pain and despair more than the average person

You're typically pessimistic, others would call you extremely negative

You are excessively cautious and don't take risks

You're uncomforatble in social situations. You want to be sociable but you are not always sure how to act

Your feelings are hurt easily and it can make you cry at the drop of a hat

You sometimes have feelings of hopelessness, or feel "What's the point?"

You are very sensitive to what others think about you

You are overly self cautious, others might call you paranoid

You often think that others are making fun of your behind your back

You have bad memories that you just can't let go, especially emotional hurt or humiliation

Behavioural Characteristics of a Right Brain delay *

You have a hard time following the rules of good communication, you say inappropriate things, talk at the wrong time, and you are not particularly expressive when talking

You have, or others tell you, that you have a hard time staying focused on the task at hand or paying attention to what is being said or done around you for more than a few minutes

You sometimes think you have or others accuse you of having adult ADHD, or you have been diagnosed with it

You obsess over practically everything. You often think or others have told you that you act like you have obsessive-compulsive disorder or you have been diagnosed with it

You have manic-depressive highs and lows to the degree that you or others feel you might have bipolar disorder or you have been diagnosed with the disorder

You frequently have feelings of deja vu, you feel like you have been somewhere or experienced an event before

You often miss the point of a story

You get stuck in set behaviour and can't let it go, e.g. you can't transition easily to a a new thought, action or idea

You never feel a sense of guilt or remorse

You lack social tact and feel socially isolated

You manage your time poorly, you are always late for appointments and meetings

You are a neat freak and can't stand when something is out of order

You can't sit still, you are impulsive, compulsive and hyperactive

You have a hard time getting to sleep because your mind is always racing

You hate throwing things out and may even be accused of being a hoarder

You're generally uncooperative

You have extreme eating habits, possibly to the point of an eating disorder, especially bulimia

You often appear to others as bored, aloof and abrupt

You are considered strange by others or you were considered strange as a kid

You don't have a lot of friends, new friends you make seem to drift away

You don't particularly enjoy the company of others

You act silly or giddy at inappropriate times in the presence of others

You talk incessantly and are known to others as "a talker"

You tend to ask or have been told that you ask repetitive questions and talk in circles, but never really get to the point

You could care less about social trends and fashion

You've been wearing the same hair style for years

You have been described as a control freak

Behavioural Characteristics of Left Brain Delay *

You tend to be oblivious to rules and regulations e.g. you seem to "attract" parking and speeding tickets

You have a tendency to exaggerate or lie

You can feel terrible shame or crippling guilt even when you have not done anything terribly wrong

You frequently have a feeling of foreboding or sick feeling in the stomach for no discernible reason

You tend to procrastinate

You are very shy, especially around strangers

You have a tendency to stutter or stammer

You have poor self esteem, you feel like a loser and you feel others think of you that way

You have, or others say you have an inferiority complex. You don't feel you're as smart as others

You hate busywork, such as doing paperwork or paying the bills

You are not good at following routines and establishing habits

You get perplexed, frustrated or annoyed when you have to follow multiple step directions

You tend to jump to conclusions or have been told you jump to conclusions too quickly

You make mistakes because you don't read or follow directions

You are extremely messy

You follow fads and trends and are beholden to the latest fashions

You were bored in school or hated school work

You just hate being alone

You are a daydreamer and are constantly drifting off in thought

You have a hard time doing just one thing at a time

You constantly stop one activity or thought and start before anything is finished

You have an addictive personality e.g.you have been addicted to drugs, alcohol, cigarettes, gambling, sex etc

Cognitive Characteristics of a Right Brain Delay *

You have difficulty recalling the date, time or place of important events in your life e.g. you don't just forget birthdays and anniversaries, you sometimes have to pause to remember your age or day and year you were married

You have trouble staying on topic during a conversation or at a meeting

You have trouble repeating a story as told or explaining directions

You have a tendency to fly off the handle to common annoyances e.g. an overflowing sink or an overheated engine

You have difficulty interpreting abstract language e.g. you may not get a joke or understand a metaphor

You cannot mentally rotate objects in space e.g you have a hard time imagining how furniture would look in a different position in the room

You can't seem to recognise faces of people you know who you haven't seen in years

You do not remember much or almost anything about your childhood

You have a poor sense of direction

You have difficulty using and understanding innuendo and connotation e.g. you can't take a hint

You don't "get it" when someone uses irony and sarcasm

You don't get the moral in a story or the point that the author is trying to make

You get so stuck in details that you have difficulty making decisions

You have a hard time making decisions because you tend to overanalyse everything

You have an obsessive interest in unusual topics such as trains, rocks, stamps, comic books and the like

You are frequently growing increasingly impatient

You speak aloud what's on your mind

You get very close to people when speaking to them, others would call you a space invader

You are extremely direct to the point of being considered rudeYou have difficulty recalling the date, time or place of important events in your life e.g. you don't just forget birthdays and anniversaries, you sometimes have to pause to remember your age or day and year you were married

You have trouble staying on topic during a conversation or at a meeting

You have trouble repeating a story as told or explaining directions

You have a tendency to fly off the handle to common annoyances e.g. an overflowing sink or an overheated engine

You have difficulty interpreting abstract language e.g. you may not get a joke or understand a metaphor

You cannot mentally rotate objects in space e.g you have a hard time imagining how furniture would look in a different position in the room

You can't seem to recognise faces of people you know who you haven't seen in years

You do not remember much or almost anything about your childhood

You have a poor sense of direction

You have difficulty using and understanding innuendo and connotation e.g. you can't take a hint

You don't "get it" when someone uses irony and sarcasm

You don't get the moral in a story or the point that the author is trying to make

You get so stuck in details that you have difficulty making decisions

You have a hard time making decisions because you tend to overanalyse everything

You have an obsessive interest in unusual topics such as trains, rocks, stamps, comic books and the like

You are frequently growing increasingly impatient

You speak aloud what's on your mind

You get very close to people when speaking to them, others would call you a space invader

You are extremely direct to the point of being considered rude

Cognitive Characteristics of a Left Brain Delay *

You have a problem remembering details such as street names or important dates

Colors look dull to you lately

You have trouble remembering names and phone numbers

You cannot learn by reading

You have difficulty executing a plan, such as following a recipe or building a model

You have poor analytical skills e.g. you can't think logically in a stressful situation or analyse your odds of winning or losing in a game

You have no sense of time, you are always late

You have trouble prioritising e.g. you have difficulty knowing what to do first or what is most important

It is unlikely you would take the time to read the instruction manual before trying something new

You have the tendency to miss small words when reading or omit them when you write

You have difficulty learning new material and your reading is too slow and laborious

Names and words get caught on the tip of your tongue

You need to hear or see concepts many times in order to learn them

You believe you were or are dyslexic

You took special education classes in primary school or high school

You say you are poor at maths

You are a bad speller

You are not particularly good at gramatically correct writing

You studied a foreign language but can't recall or can barely recall it

You have difficulty or can't describe the nature of your relationships in emotional terms, such as what your relationship was with your mother when you were growing up

You can't remember details of your childhood such as the address you lived, your phone numbers or your teachers names

Immune Characteristics of Right Brain Delay *

You tend to have an over active immune response - allergies

You have a sensitivity to a food substance, such as casein or gluten

You have or have had an autoimmune disorder such as asthma, eczema, lupus, psoriasis or rheumatoid arthritis

You have more than one autoimmune disorder

You have little white bumps on your skin, especially the back of your arms

You crave certain foods, especially dairy and wheat products

You have been diagnosed with low thyroid function

You feel like you're a little drunk or feel off balance after eating certain foods

Immune Characteristics of Left Brain Delay *

You have a problem with chronic ear, throat or respiratory infections

You are prone to benign tumours and/or cysts or you have had a cancerous tumour

You've taken or frequently take a lot of antibiotics or anti viral medications

You catch a lot of colds, more than 2/year

It takes you a long time to feel 100% after an illness

You feel you have to get a flu shot every year or you will get the flu, You sometimes get it even with a flu shot

You have a problem with chronic yeast or fungal infections and/or have been diagnosed with candidiasis or thrush

You have or have had stomach ulcers

You've had pneumonia within the past 7 years

You have recurrent viral outbreaks, such as herpes or shingles

You have had or still have Lyme disease

You've had your tonsils and adenoids removed because of chronic infections

Metabolic Characteristics of a Right Brain Delay *

You have frequent bowel troubles with constipation and/or diarrhoea

You have a rapid heart rate or a sudden increase in heart rate (Tachycardia, above 90 bpm)

Your blood pressure is 10 points or more higher when taken on your right arm than your left

You perspire more on the right side of your body than your left

Metabolic Characteristics of Left Brain Delay *

Your blood pressure is 10 points or more higher when taken on your left arm than on your right arm

You sweat more on the left side of your body

You have or have had irregular heartbeat, such as arrhythmia or a heart murmur

Your left hand loses circulation and takes longer to warm up when exposed to the cold