The 100 Checklist TRACKING YOUR SHIFTS: THE ONE HUNDRED Name *FirstLastDateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ChoosePreOngoingPostDateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please check off any item that sounds right for you. If you are unsure, use the past week as your guide. It’s fine to add comments if you wish.CheckboxesItchy or irritated nose, sneezingWheezingCatch cold too oftenRun downTiredAwake too long when you go to bedWaking up during the nightWaking up before you want toDifficult to wake up in the morningBad dreamsDifficulty breathing at nightOut of bed but not knowing how you got thereSkin difficult to manageHair weaker or less lustrous than you’d likeNails weak, flaking or tearingBlurry vision at timesAreas where you can’t see anythingSpots floating in front of youDifficult to hearRinging in your earsEars hurt insideSmells seem different or lostNose gets blockedGrinding your teethThings taste differentVoice hoarse or soreCan’t get enough airHeart too fast or jumpyPulsing or throbbing in your headHeart skips a beatWorld spinning around youMight throw upTummy hurtsGassy, bloatedSensitive digestionUpset stomachDifficulty going to the bathroomEat when not hungry, or not feeling hungryTrouble eating sweetsUrges to eat sweet thingsSensitive to heat or coldSlowed down or speeded upMoody at certain times of the monthHot flashesProblems from being of a “certain age”Not interested in your partnerToo interested in your partner or other peopleStiff and soreAreas that really hurt when touchedMuscles hurtFatiguedPains in your headGoing to pass outLose consciousnessDifficult to remember thingsDifficult to find your wordsDifficulty readingDifficult to speak sometimesShakyWeakToo activeCan’t balance on one legMoving your head or saying words you don’t intendDifficulty paying attentionEasily distractedMake a lot of mistakesDisorganizedDifficult to complete tasksLose your train of thoughtDifficult to complete studies or workGet into trouble at school or workMix up numbers or letters sometimesDifficult to know how things fit togetherDifficulty with some subjectsNeed to go to the bathroom but hard to startLose your urine sometimesDifficult to control going to the toiletStinging sensations when going to the bathroomDrink too much sometimesSmoke cigarettesConcerns about eatingNeed caffeine to get goingEnjoy marijuanaHabits that concern youMoodyFeeling low or flatFeel sadConcerned about thingsFeel terrified sometimesMull about thingsThoughts you’d like to stop but can’tNeed to do things over and overEat more food than you can comfortably eatCareful to never eat too muchMake yourself throw upDifficult to do things you’d like to doOthers are against youGet into trouble for your behaviorFeeling angryOverwhelmNote: Any concerns mentioned are intended as examples only and not meant to suggest that NeurOptimal® treats, mitigates, cures, or diagnoses any listed concern. Instead, identified concerns and medication use are one of many ways to measure shifts in brain functioning and perception. NameSubmit
