Attention and Focus Combined Assessment 10-18-16 - Unofficial

Attentional Control
&
Mental
Concentration
Assessment:
Combined
(FOR A MENTAL FITNESS TRAINING PROGRAM ELIGIBILITY)
This Mental Fitness Training Assessment Form for Attention Control &
Mental Concentration is for reference and informational purposes only. This
evaluation is not applicable to nor does it qualify as a substitute for any medical
mental health screening that is mandated to be provided by a physician or
mental health counselor. The symptoms discussed between Candidate and
Trainer are interpreted from the Diagnostic and Statistical Manual of Mental
Disorders 4th Edition (DMS-IV) . Conditions may be related to Attention
Deficits, Inattention, Hyperactivity, Impulsivity, Oppositional Defiance, and
other Mental Health issues. Anyone at risk of or suspecting a harmful,
diagnosable mental or physical health condition should consult a physician.
Mental Fitness Training Assessment for Attention Control & Mental Concentration - Official Form 1A
2008 Dynamic Mental Fitness Training, Inc. All Rights Reserved.

NAME AGE DATE
Is the Candidate currently Is the Candidate currently Has the Candidate received
prescribed or taking any receiving any form of mental health any form of mental or
medications that affect mental treatment, counseling, or physical health diagnosis
faculties or cognitive professional advice; or, has had such that might noticeably affect
performance? services within the past year? cognitive performance?
Symptomatic Characteristics Does Not Rarely Sometimes Often Habitually

Occur Occurs Occurs Occurs Occurs
When involved in a mundane or boring

task, I get caught up in some thought or
another.
When theres nothing much to do, my

imagination starts thinking or fantasizing
about all kinds of stuff.
For most things I have to do and places I

have to be, I wish I was someplace else and
doing something more interesting with
more interesting people.
Riding or driving in a vehicle for some

distance, I get caught up in thoughts
without realizing it.
I forget what Im supposed to be doing or

where Im supposed to be going or why,
and either I have to keep reminding myself,
or other people keep reminding me.
When people are speaking to me, my

attention can fade out, and my mind drift
off so that Im not really listening.
I find myself pretending to know what

someone has been saying to me
because I had been thinking of
something else at the time.
I draw a blank when trying to remember

something that happened
recently, or a name, or a phone number.
My mind goes fuzzy on me when trying to

come up with an answer to a problem or
issue, or when Im trying to figure or work
something out quickly
I am uncomfortable or anxious when

takings tests and exams no matter how
much I prepare.
I find having to work with a lot of little

details to be boring and frustrating.
I leave out or overlook details which causes

me to make mistakes without meaning to.
I misplace or lose minor items I could

easily keep track of if I really wanted to.
I easily spend a long time doing

something I find fun or interesting, but
when something is dull, Im quickly bored,
frustrated, or quickly distracted.
I am prone to surprise bumps, stumbling,

accidents; fumbling or dropping things or
making errors.
When Im doing something, I get distracted

by sights and sounds going on around me.
I get off track and end up doing something

unrelated to the task I started out doing.
Its hard to get back into whatever I was

working on once something takes my
attention away from it.
When people approach and start talking to

me about something else other than what
Im working on, I stop my task.
When the option to do something more fun

or interesting pops up in the middle of my
task, I go with the fun or interesting thing.
The symptoms listed are interpreted from

the Diagnostic and Statistical Manual of
Frequency Scores: 1 2 3 Mental Disorders 4th Edition (DMS-IV) .
Conditions may be related to Attention
Deficits, Inattention, Hyperactivity, Impul-
Does Not Occur and Rarely Occurs sivity, Oppositional Defiance, and other
Mental Health issues. Anyone at risk of or
Rate a 0 Score suspecting a harmful, diagnosable mental
or physical health condition should consult
a physician.
NAME AGE DATE

I jump into conversations too quickly

when I really should stay out of it or just
listen carefully and wait my turn.
I start talking about something and it just

snowballs and drags on too long until I end
up wasting time I could have used better.
Even when I know it is best to remain

silent about something, I end up talking
about it anyway.
I try to control what I say to people and

when I say it, but find myself in situations
where I speak the wrong thing at the
wrong time, to the wrong person.
I give into the urge to behave a certain

way in front of others so that they will like
me, even though I dont feel like it is my
natural self.
I hang around or associate with people

who I know are not best for me to be
around, wishing I could be around some
better people.
Stressful pressures dont seem to leave me

alone, putting me on edge.
I replay unpleasant encounters with others

over and over again and cant seem to just
let it go.
I take what other people say personally to

the degree that I can hold a grudge that
pops up when I see them again.
My attention is drawn to the emotional

drama going on around me and I find
myself talking about it.
I get pestered by negative or fearful

thoughts and ideas.
Once a thought gets into my head, I have a

hard time forgetting it and moving on to
something else.
A bothersome sense of uncertainty and

anxiety occupies my thoughts.
I have continuous mental conversations

with myself,.
I second guess myself.
My mind engages in habitual negative

self-talk or pessimistic internal conversa-
tion.
My thoughts dwell on the past and bring up

painful events and situations I regret or
would like to forget.
I rerun scenarios of what I wish I would

have said to someone, or how I wish I
would have handled a situation.
I have a hard time becoming relaxed or

getting to sleep quickly because thoughts
keep bombarding me.
I get weary with all my constant thinking.

a physician.
AREAS AND DEGREES OF NEGATIVE IMPACT
AND UNDESIRABLE EFFECT
EMPLOYMENT/CAREER MARRIAGE/RELATIONSHIPS MONEY/FINANCES
BUSINESS FAMILY/SIBLINGS HOME ENVIRONMENT
SCHOOL/CLASS FRIENDS/SOCIAL LIFE OTHER
CRITICAL SYMPTOM INDICATORS
Impairs Now Happens Often Causes Major

No Real and Then with Enough to Significant Impairment
Symptom #s Average Cause Me Some Performance & Painfully
Areas Impacted Concern
Performance Problems Problems Problematic
NON-CRITICAL AGGREGATE IMPACT COMMENTS:
TRAINER EVALUATION NOTES:
Mental Fitness Training Assessment for Attention Control & Mental Concentration - Official Form 1A
Consistent
Mental Focus
Assessment
(FOR A MENTAL FITNESS TRAINING PROGRAM ELIGIBILITY)
This Mental Fitness Training Assessment Form for Long-Term Mental

Focus is for reference and informational purposes only. This evaluation is not
applicable to nor does it qualify as a substitute for any medical mental health
screening that is mandated to be provided by a physician or mental health
counselor. The symptoms discussed between Candidate and Trainer are
interpreted from the Diagnostic and Statistical Manual of Mental Disorders 4th
Edition (DMS-IV) . Conditions may be related to Attention Deficits, Inattention,
Hyperactivity, Impulsivity, Oppositional Defiance, and other Mental Health
issues. Anyone at risk of or suspecting a harmful, diagnosable mental or
physical health condition should consult a physician.
Mental Fitness Training Assessment for Long-Term Mental Focus - Official Form 1A

NAME AGE DATE

The prospect of reading non-entertaining

material is disturbing for me.
When reading, I repeatedly lose my place

on the page and have to find my way back
to the right spot.
I get to the end of a paragraph of text and

cant well remember what I just finished
reading.
When reading, I use my finger or a straight

edge to guide my eyes along the words or I
have to read aloud so not to lose my place.
My handwriting is rushed and not neat.
I avoid reading detailed written

instructions.
I have difficulty focusing on mundane or

boring tasks that require undivided atten-
tion.
I put off and procrastinate when faced with

uninteresting duties.
When I have a reasonable list of things to

do, more than a few tasks never seem to get
done.
My mind tends to wander to thinking of

something else when doing normal daily
tasks.
Given a choice between an entertaining task

and a boring but necessary duty, I tend to
choose the entertaining task, even when I
know I shouldnt.
I get more done in a noisy, distracting

environment than when in a quiet, peaceful
one.
Ideas come to me quickly and easily, but

are soon forgotten.
I have great ideas but most of the time I

dont do much about them.
I can think of several things over the past

year Ive started that didnt get finished.
Although I have good intentions, I promise

others Ill do something, but I just seem to
get caught up in other things.
I have a problem meeting deadlines.
I know deep down that Im not doing all

Im capable of.
When theres something I really want, it

doesnt happen because I lose my
Momentum or end up doing another thing.
Theres something I really want to do or

achieve, but I am not doing enough to make
it happen.

a physician.
NAME AGE DATE

I dont feel any strong motivation even

though there are high expectations for me.
I know I have the potential to achieve

something important, but Im not clear on
where Im going or what to do.
I make plans, but negative thoughts come

up that keep me from taking the necessary
action.
I resist dealing with minor details because I

find them boring or my mind goes blank or
fuzzy when thinking about them.
I come up with great ideas, but struggle at

establishing detailed plans or hammering
out long term objectives.
I am excited about starting a project, but my

enthusiasm fades away and then the effort
seems like a chore.
Regretful thoughts of things I havent done

or achieved run through my mind.
Thoughts run through my mind about what

might happen if I dont get my act together
soon.
Im more productive around other people,

but when its just me, I slow down or lose
my momentum.
Im okay when working by myself, but

when other people are around Im less
productive.
I put off tasks that require continuous effort

of detailed attention on my part.
I neglect to adhere to set schedules.
I am somewhat disorganized in more than

one area of my life.
I have difficulty organizing tasks, activities,

or projects involving other people.
I feel like I do a lot of work and make a lot

of effort, but nothing much seems to get
done.
I work well and am very productive but feel

like Im not achieving my objectives.
I am concerned with employment or finan-

cial difficulties or both.
I run around like crazy trying to keep things

from falling apart.
My life feels out of control no matter how

hard I work at things.
I think that my situation and the people

around me keep me from doing and being
and getting what I really want in life.

a physician.
AREAS AND DEGREES OF NEGATIVE IMPACT
AND UNDESIRABLE EFFECT
EMPLOYMENT/CAREER MARRIAGE/RELATIONSHIPS MONEY/FINANCES
BUSINESS FAMILY/SIBLINGS HOME ENVIRONMENT
SCHOOL/CLASS FRIENDS/SOCIAL LIFE OTHER
CRITICAL SYMPTOM INDICATORS
Impairs Now Happens Often Causes Major

No Real and Then with Enough to Significant Impairment
Symptom #s Average Cause Me Some Performance & Painfully
Areas Impacted Concern
Performance Problems Problems Problematic
NON-CRITICAL AGGREGATE IMPACT COMMENTS:
TRAINER EVALUATION NOTES:
Mental Fitness Training Assessment for Starting And Staying On Task - Official Form 1A
ANALYZING BASELINE PERFORMANCE TIMES
SelfAssessment Ratings:
Habitually Occurs = 3 Often Occurs = 2 Sometimes Occurs = 1 Rarely Occurs = 0 Does Not Occurs = 0
Your Baseline Performance Score combined with your Assessment Scores can often point toward an area of
weakness or strength in regards to your consistent abilities in Mental Concentration, Mental Focus, and Willpower. The
better your performance times, consistently, the less likely you are to demonstrate behaviors, patterns, and habits
indicative of weaker cognitive strength. As your times improve across the spectrum, symptoms of weakness are likely to
decrease correspondingly.
BASELINE PERFORMANCE TIME: 0 TO 5 MINUTES

Cognitive Control Skill Level - WEAK
CONCENTRATION ASSESSMENT FOCUS ASSESSMENT WILLPOWER ASSESSMENT
Scoring Many 1s & 2s Scoring Many 1s & 2s Scoring Many 1s & 2s
Scoring Numerous 2s & 3s Scoring Numerous 2s & 3s Scoring Numerous 2s & 3s

Cognitive Control Skill Level - MODERATE
Scoring Some 1s Scoring Some 1s Scoring Some 1s
Scoring A Few 2s Scoring A Few 2s Scoring A Few 2s
Almost No 3s Almost No 3s Almost No 3s

Cognitive Control Skill Level - STRONG
Scoring Few 1s Scoring Few 1s Scoring Few 1s
Almost No 2s Almost No 2s Almost No 2s
No 3s No 3s No 3s

Attention and Focus Combined Assessment 10-18-16 - Unofficial

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Attention and Focus Combined Assessment 10-18-16 - Unofficial

Hochgeladen von

Copyright:

Verfügbare Formate

Attentional Control

2008 Dynamic Mental Fitness Training, Inc. All Rights Reserved.

Symptomatic Characteristics Does Not Rarely Sometimes Often Habitually

When involved in a mundane or boring

When theres nothing much to do, my

For most things I have to do and places I

Riding or driving in a vehicle for some

I forget what Im supposed to be doing or

When people are speaking to me, my

I find myself pretending to know what

I draw a blank when trying to remember

My mind goes fuzzy on me when trying to

I am uncomfortable or anxious when

I find having to work with a lot of little

I leave out or overlook details which causes

I misplace or lose minor items I could

I easily spend a long time doing

I am prone to surprise bumps, stumbling,

When Im doing something, I get distracted

I get off track and end up doing something

Its hard to get back into whatever I was

When people approach and start talking to

When the option to do something more fun

The symptoms listed are interpreted from

Symptomatic Characteristics Does Not Rarely Sometimes Often Habitually

I jump into conversations too quickly

I start talking about something and it just

Even when I know it is best to remain

I try to control what I say to people and

I give into the urge to behave a certain

I hang around or associate with people

Stressful pressures dont seem to leave me

I replay unpleasant encounters with others

I take what other people say personally to

My attention is drawn to the emotional

I get pestered by negative or fearful

Once a thought gets into my head, I have a

A bothersome sense of uncertainty and

I have continuous mental conversations

I second guess myself.

My mind engages in habitual negative

My thoughts dwell on the past and bring up

I rerun scenarios of what I wish I would

I have a hard time becoming relaxed or

I get weary with all my constant thinking.

The symptoms listed are interpreted from

BUSINESS FAMILY/SIBLINGS HOME ENVIRONMENT

SCHOOL/CLASS FRIENDS/SOCIAL LIFE OTHER

CRITICAL SYMPTOM INDICATORS

Impairs Now Happens Often Causes Major

NON-CRITICAL AGGREGATE IMPACT COMMENTS:

TRAINER EVALUATION NOTES:

This Mental Fitness Training Assessment Form for Long-Term Mental

2008 Dynamic Mental Fitness Training, Inc. All Rights Reserved.

Symptomatic Characteristics Does Not Rarely Sometimes Often Habitually

The prospect of reading non-entertaining

When reading, I repeatedly lose my place

I get to the end of a paragraph of text and

When reading, I use my finger or a straight

My handwriting is rushed and not neat.

I avoid reading detailed written

I have difficulty focusing on mundane or

I put off and procrastinate when faced with

When I have a reasonable list of things to