Part 1: Presenting Concerns and Impact

What primary challenges or symptoms prompted you to complete this assessment at this time? *

What specific outcomes or improvements are you hoping to achieve through professional evaluation and support? *

To what extent do you feel your cognitive processes or emotional responses differ from what you perceive as typical for others? *

Describe how your unique way of thinking, focusing, or processing information impacts your daily life and work as a business owner. *

Part 2: Detailed Symptom Presentation - Focus and Executive Function

Please rate the frequency and intensity of the following challenges related to focus and attention over the past 6 months: (1 = Never/Not at all, 5 = Always/Severely)

Part 3: Stress, Emotional Regulation, and Sensory Processing

Describe your typical physiological and emotional responses when under high stress. *

How would you describe your current ability to regulate emotions, particularly when experiencing frustration, anger, or sadness? *

Do you experience heightened sensitivity to certain sensory inputs (e.g., specific sounds, bright lights, textures, smells) or significant distress due to changes in routine or unexpected events? *

Yes

If yes, please describe the specific sensitivities or reactions:

Describe any challenges you experience in social interactions, professional networking, or understanding social cues. *

Part 4: Medical History and Contributing Factors

On the following slides, please indicate if you have a history of or are currently experiencing any of the following conditions or symptoms that may impact your focus, energy, or overall well-being. (Check all that apply)

Neurological/Cognitive: *

Diagnosed ADHD, ASD, Dyslexia, Dyspraxia, Dyscalculia, Tourette Syndrome, Acquired Neurodiversity

Traumatic Brain Injury (TBI) or head injuries

Migraines or chronic headaches

Memory difficulties

Brain fog

Gastrointestinal/Dietary: *

Irritable Bowel Syndrome (IBS-C or IBS-D)

Inflammatory Bowel Disease (e.g., Celiac, Crohn's)

Food intolerances or sensitivities (e.g., to wheat, dairy)

Leaky Gut (diagnosed or suspected)

Chronic indigestion or acid reflux

Other Physical/Systemic: *

Chronic fatigue or low energy

Sleep disorders (e.g., sleep apnea, insomnia)

Micronutrient deficiencies

Dehydration

Chronic pain (e.g., joint pain, back pain)

Environmental toxin exposure

Side effects from prescription medications or supplements

Infections (e.g., Lyme disease)

Genetic factors known to impact health or focus (e.g., MTHFR mutation)

Please list any current medications, supplements, or dietary changes you are taking, including dosage. *

Describe any significant past medical history, surgeries, or major life events that you believe are relevant to your current symptoms. *

Part 5: Body Awareness and Functional Habits

Describe any physical sensations, tension, or discomfort you regularly experience in your body. *

How would you describe your posture and movement patterns, especially when sitting for extended periods or engaging in daily activities?

To what extent do you feel connected to your body, or aware of internal cues (e.g., hunger, fatigue, stress signals)? *

Describe your typical sleep patterns (e.g., hours of sleep, ease of falling asleep, waking during the night, feeling rested upon waking). *

Part 6: Past Treatments and Future Directions

Please list any healthcare providers, therapists, or alternative practitioners you have consulted for your focus issues or related symptoms in the past, along with the approximate dates and outcomes. *

What types of treatments or interventions have you found most (or least) helpful in managing your symptoms? *

Are you open to exploring various treatment modalities, including both conventional (allopathic) medical approaches and complementary therapies (e.g., acupuncture, chiropractic care, hypnotherapy, somatic experiencing, nutritional therapy)? *

Yes

Unsure

If you are open to complementary therapies, are there any specific modalities you have considered or would like to learn more about? *

Thank you for providing this detailed information. Your responses are crucial in helping our network of professionals—including business, finance and IT professionals, medical doctors, mental health specialists, dietitians, acupuncturists, chiropractors, occupational therapists, behavioral therapists, hypnotists, and somatic practitioners—gain a comprehensive understanding of your unique situation. This will enable them to provide the most targeted and effective next level questions to target education and options to help guide you to greater health and success. We will review your responses and discuss potential next steps during your upcoming consultation.