Mind & Health Quiz 1Personal Details2Executive Function3Creative Expression4Communication5Auditory Processing6Social & Emotional7Motor Coordination8Stress Response Our Total Mind & Health Quiz will help us identify your mental health & physical capabilities. Estimated Time: Under 10 minutes. RelationshipSelfParentTeacherEmail First Name: (person completing screening)Last Name: (person completing screening)First Name: (person being screened)Last Name: (person being screened)Birth Date MM slash DD slash YYYY GenderMaleFemaleOtherPhoneCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Reason for Scale: (limit 2500 characters with spaces) Executive function is an umbrella term for a set of high-level mental processes that control and regulate other abilities and behaviors. They include the ability to initiate and stop actions, to monitor and change behavior as needed, and to plan future behavior when faced with novel asks and situations. Executive functions allow us to anticipate outcomes and adapt to changing situations. Examples: attention, memory, behavior, organization, time management, self control Trouble staying focused Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty retaining new information Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty adapting to changing environments Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty with organizational skills Strongly Disagree Disagree Neutral Agree Strongly Agree Trouble initiating/completing tasks Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty controlling impulses Strongly Disagree Disagree Neutral Agree Strongly Agree Your ability to express yourself creatively involves original & open thinking, imagination, problem solving, and movement to create something new and/or respond to opportunities. Examples: musicality, opening thinking, visual arts, creative writing, innovation, problem solving Difficulty developing music skills Strongly Disagree Disagree Neutral Agree Strongly Agree Is closed minded Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty developing visual art skills Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty with creative writing Strongly Disagree Disagree Neutral Agree Strongly Agree Does not come up with original ideas Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty problem solving Strongly Disagree Disagree Neutral Agree Strongly Agree Communication is your ability to exchange information, thoughts, and opinions through verbal and written expression including speech, language, voice and writing; as well as non verbal expression such as gesture, facial expressions, and body language. Examples: verbal comprehension, oral & written communication, voice quality, reading comprehension, understood by others, understanding body language Misunderstands what others are saying Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty expressing thoughts or ideas Strongly Disagree Disagree Neutral Agree Strongly Agree Poor vocal/speaking quality Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty understanding written information Strongly Disagree Disagree Neutral Agree Strongly Agree Hard to be understood by others Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty understanding other’s body language/facial expressions Strongly Disagree Disagree Neutral Agree Strongly Agree Auditory processing is your ability to understand and make sense of what you hear. Difficulty processing auditory information can have a negative impact on learning, thinking, communication and relationships. Examples: listening, following verbal directions, focusing with background noise, comfort with sound, understanding tone of voice, sound discrimination Finds it difficult to listen Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty following verbal instructions Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty focusing in background noise Strongly Disagree Disagree Neutral Agree Strongly Agree Finds some sounds painful or uncomfortable Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty understanding meaning in others’ tone of voice Strongly Disagree Disagree Neutral Agree Strongly Agree Confuses similar sounding words Strongly Disagree Disagree Neutral Agree Strongly Agree Your ability to relate to others, manage emotions, resolve conflicts, understand and respond to social situations is impacted by your social skills and emotional intelligence. Examples: self-confidence, compassion, social interactions, interpersonal relationships, mood regulation, conflict resolution Has a low self-image Strongly Disagree Disagree Neutral Agree Strongly Agree Shy and avoids interpersonal contact with people Strongly Disagree Disagree Neutral Agree Strongly Agree Has poor social skills Strongly Disagree Disagree Neutral Agree Strongly Agree Trouble maintaining relationships with others Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty managing mood/emotions Strongly Disagree Disagree Neutral Agree Strongly Agree Uncomfortable with new situations/trying new things Strongly Disagree Disagree Neutral Agree Strongly Agree Motor coordination is the harmonious functioning of body parts that involve movement including: gross motor skills such as walking, skipping, running and throwing; fine motor movement such as handwriting, buttoning a shirt, and keyboarding; and motor planning, the ability of the brain to conceive, organize and carry out purposeful movements. Examples: balance, body awareness, coordination, fine motor skills, gross motor skills, activity level Clumsy, stumbles, difficulty with balance Strongly Disagree Disagree Neutral Agree Strongly Agree Poor sense of personal space, body awareness Strongly Disagree Disagree Neutral Agree Strongly Agree Uncoordinated body movement, poor athletic skills Strongly Disagree Disagree Neutral Agree Strongly Agree Messy handwriting, poor fine motor skills Strongly Disagree Disagree Neutral Agree Strongly Agree Poor sense of rhythm and/or timing of movement Strongly Disagree Disagree Neutral Agree Strongly Agree Atypical drive for movement and/or touch Strongly Disagree Disagree Neutral Agree Strongly Agree Your body and brain is hard-wired to react to stress to protect you against threats, whether real or imagined. But, if your mind and body are constantly on edge because of excessive stress in your life, you may face serious health problems. That's because your body's "fight-or-flight reaction" ‐ its natural alarm system ‐ is constantly on. Examples: stress reduction, relaxation, less overwhelmed, lower tension, better sleep, reduce nervous habits Does not tolerate stress well Strongly Disagree Disagree Neutral Agree Strongly Agree Has difficulty relaxing Strongly Disagree Disagree Neutral Agree Strongly Agree Feels overburdened with everyday tasks Strongly Disagree Disagree Neutral Agree Strongly Agree Feels tense and anxious Strongly Disagree Disagree Neutral Agree Strongly Agree Difficulty falling or staying asleep Strongly Disagree Disagree Neutral Agree Strongly Agree Tiredness at the end of the day Strongly Disagree Disagree Neutral Agree Strongly Agree This field is hidden when viewing the formYour Test Score Δ