NMT© CNS Functional Status Questionnaire for Caregivers and Providers This questionnaire was created by Stephen J. Bradley LICSW, LMHC, based upon the NMT Clinical Practice Tools developed by Bruce D. Perry, M.D., Ph.D. Copyrights are retained by Dr. Perry and The Neurosequential Network in all of the content herein. Please do not copy, reproduce or replicate without the written permission of The Neurosequential Network. Thank you. I have read and agree to the copyright disclaimer above Name of Person Completing This Form: Date Form Completed: Client Initials: Please complete each item to the best of your ability, thank you! Brainstem Functions Cardiovascular System / ANS Question Frequently Sometimes Rarely When upset, do you notice any changes in their breathing? Question Yes No Unknown Heart rate within normal limits? Blood pressure within normal limits? When upset how long does it take to calm down? 5 mins 10 mins 15 mins 20 mins 30 mins 45 mins 60 mins >60 mins How is circulation to fingers / toes? Within Normal Limits Poor Unknown Comments: Autonomic Regulation Question Frequently Sometimes Rarely Any stomach/digestive problems (diarrhea, constipation, irritable bowel)? Any problems with skin (dermatitis, sensitivities, hives, eczema, etc)? Diabetes? None noted/reported Yes-Type 1 Yes-Type 2 Difficulty with sleep apnea, snoring, breathing in sleep? Any history of SIDS-like episodes? None noted Yes-Sleep Apnea Yes-Snoring Yes-Both Yes-SIDS-like episodes Any excessive sighing/yawning or asthma? None noted Yes-excessive sighing/yawning Yes-asthma Yes-both Comments: Temperature Regulation/Metabolism Question Frequently Sometimes Rarely Any issues with being "too hot" or "too cold" – keeping warm or staying cool? Skin flushing/sweating, or chills? Any history of eating problems (picky eater, hoarding food, eating way too much, vomiting or reflux/rumination)? None Noted Yes-Reflux/Rumination Yes-Hoarding Food Yes-Picky Eater/Eating Way Too Much Yes-More than One of These Any issues with weight loss/gain (metabolism)? None noted Yes-weight gain Yes-weight loss Yes-fluctuating weight Comments: Extraocular Eye Movements Question Frequently Sometimes Rarely Not Tested Any difficulty with eyes being able to track objects as they move closer/farther away (near eye convergence)? Question 3 or greater Lower than 3 Untested Eye Roll Test Any problems with fast or slow blinking, eye tics, or irregular movement of eyes? None Noted Yes-Blinking/Eye Tics Yes-Irregular Movement of Eyes Yes-More than One of These Comments: Suck/Swallow/Gag Question Frequently Sometimes Rarely Any problems with gulping or swallowing food? Do they need to suck on things frequently (candy, fingers/thumb) etc? Need to chew gum or have something in mouth a lot? Question Documented None Noted History of PICA? Question Frequently Sometimes Rarely Any problems with gagging when eating or drinking? Demands for soft or smooth food textures? Difficulty chewing food, taking pills? Comments: Attention/Tracking Question Frequently Sometimes Rarely Difficulty with focusing attention for a chunk of time (maintaining focus for at least 3 mins at age 3)? Easily distractable making it difficult to complete tasks? Able to shift attention from one thing to another in a smooth/easy way? Difficulty following directions or ending one activity and beginning another? If present, how significant are academic and/or social challenges due to difficulties with attention? Not Present Mild Moderate Severe Comments: Diencephalon/Cerebellum Functions Feeding/Appetite Question Frequently Sometimes Rarely Issues with reflux/rumination? Any "odd" food preferences? Any refusal of food? Question Documented Some Concerns None Noted History of Anorexia/Bulimia? Use of food to self soothe? If so then how often? No Rarely Sometimes Frequently Always Comments: Sleep Question Frequently Sometimes Rarely Difficulty falling asleep? Staying asleep? Sleeping Alone? Nightmares/terrors? Sleep apnea? Waking at night and wandering into caregiver bed or around house? Sleep cycle problems? Excessive upset/tantrums/exaggerated activity or aggressive behavior at/around bedtime? Comments: Fine Motor Skills Question Frequently Sometimes Rarely Able to use hands as needed to grasp and do age appropriate tasks (pen, pencil, reaching and handling objects etc)? Any tremors, difficulty drawing or handwriting? Able to write with pencils and crayons? Cuts with scissors/uses glue as expected for age? Feeding/drinking with little trouble (utensils, cups, etc)? Handles blocks, beads, buttons, construction activities as expected for age? Folds paper, manages buttons and zippers, puts on/ties shoes? Creates rolls/shapes with play dough/clay? How do they do (for their age) with skills such as drawing shapes and people? Below Age Level At Age Level Above Age Level Comments: Coordination/Large Motor Functioning Question Frequently Sometimes Rarely Able to crawl, walk, run, skip, hop and stand normally? Able to balance self? Able to walk forwards/backwards heel to toe without problems? Able to kick/throw a ball? Demonstrates steady beat consistency or basic rhythm? Dizzy when spinning, turning, swinging or when feet leave the ground? Any stiff or awkward movements? Clumsiness? None noted Rarely Yes-Stiff or Awkward Movement Yes-Clumsiness Comments: Dissociative Continuum Question Frequently Sometimes Rarely Any noticeable slowing of heart rate or eye-blink rate when upset/stressed? Insensitivity to pain? Daydreaming, staring, checking out/spacing out? Do they appear physically immobilized when stressed? Any self injury (cutting, self abuse, picking at self)? Headaches? How frequent/intense? None Mild/Infrequent Moderate Severe/Frequent GI problems (constipation/diarrhea) - how frequent/intense? None Mild/Infrequent Moderate Severe/Frequent Abdominal/chest pain (without a medical condition)? How frequent/intense? None Mild/Infrequent Moderate Severe/Frequent Pseudo-seizures/absence seizures? None noted Possible/Suspected Yes-Documented Comments: Arousal Continuum Question Frequently Sometimes Rarely Easily startled? High/variable HR? Increased muscle tone/motor activity when upset? Hypervigilent (scanning for any possible threats)? Sleep problems (also see above sleep section)? Misperceptions of social interactions among/between others? Severe or prolonged tantrums? Running/biting/scratching when upset? Difficulty with transitions? Impulsivity (overall) Very Low Low Moderate High Extreme Comments: Neuroendocrine/Hypothalamic Question Frequently Sometimes Rarely Tolerates cold temperatures? Problems with too much/too little growth (in height/weight)? Dizziness/weakness? Early or late onset of puberty? Normal onset Early onset Late onset Not applicable Growth abnormalities/Obesity (medical)? None Noted Yes-Documented Hair loss None noted Some Significant Hormone issues? None noted Possibly Yes-documented Comments: Primary Sensory Integration Question Frequently Sometimes Rarely Touch hypersensitivity/defensiveness (dislikes being touched)? Difficulty getting and using information from sensory input/experience? Easily overwhelmed by loud or chaotic situations (birthday parties, malls, etc)? Dislikes shoes, clothing tags, textures or mess? Frequently mouthing objects (pencil, shirt, hands) or chewing/licking non-food items? Touching, poking, pushing others/objects frequently? Do they noticeably seek or avoid sensory input? No Seeks input Avoids input Both Comments: Limbic Functions Reward Question Frequently Sometimes Rarely Able to be happy as a result of positive interactions with others? Enjoys doing behavior that's consistent with values (i.e. being kind to someone) etc? Enjoys playing or listening to music? Any self harming behaviors (scratching, cutting, pulling scabs, head banging, severe nail biting)? Any use of substances or alcohol? Any over-use of sweet, salty, fatty foods to calm down? Has a positive (safe, age-typical) relationship with sexual behavior? Able to become absorbed in age appropriate play? Expresses joy? How comfortable are they with close proximity, eye contact and/or healthy touch? Very comfortable Somewhat comfortable Uncomfortable Very uncomfortable Comments: Affect Regulation/Mood Question Frequently Sometimes Rarely Able to manage difficult feelings when they come up? Able to feel the four major feelings (mad, sad, scared, glad)? Emotions match the situation they're in? Recognizes/responds to their own and others' feelings? Understands non-verbal communication? Overly anxious or aggressive, withdrawn when upset? How long to calm down after being upset and/or exciting activity (15 mins or longer)? <5 min 5-10 min 10-15 min 15-30 min >30 min Comments: Attunement/Empathy Question Frequently Sometimes Rarely Makes eye contact when talking with caregivers Problems with selfishness? Being inconsiderate? Shares feelings/experiences with caregivers? Shows affection towards others (physically/verbally)? Comforts others when distressed? Has close connections with others (group, family, friends, school, peers etc)? Responds to caregiver's singing, telling stories or playing together? References caregivers when exploring new places/meeting new people (age dependent)? Comments: Psychosexual Question None Noted Some Concerns Documented Any out of control sexual behavior? Any sexually hurtful behavior towards others? History of sexual abuse? None noted Suspected Documented/Reported Comments: Relational/Attachment Question Frequently Sometimes Rarely Able to form friendships and attachments with caregivers/family? Able to form and maintain age appropriate friendships? Wants and is able to engage with others? When others try to connect with them do they become fearful or have to self soothe/calm down? Aware and responsive to others around them? Any affection towards others that seems out of place or random? How is quality of connection in these relationships? Positive, Engaged Partially/Intermittently Engaged Disengaged/Disconnected How able to share with others? Easily Shares Sometimes Shares Rarely Shares Never Shares Comments: Short Term Memory/Learning Question Frequently Sometimes Rarely Any problems with remembering or having to repeat simple directions? Long term problems with remembering things? Short term problems/difficulties? Able to grasp things quickly or does it take repetition, many tries to learn something new? Grasps things quickly Takes some repetition Takes many repetitions Comments: Cortical Functioning Somato/Motorsensory Integration Question Frequently Sometimes Rarely Good at physical activities? Able to locate self in physical space/get around without difficulty? Aware of surroundings and able to respond effectively to changes in the environment? Any hallucinations/hearing/seeing things that aren't there? Comments: Sense Time/Delay Gratification Question Frequently Sometimes Rarely Aware of time passing? Accurately? Able to postpone rewards? Able to do an activity understanding/trusting that the reward will come at a later time for completing it? Comments: Communication Expressive/Receptive Question Frequently Sometimes Rarely Able to communicate effectively to others (verbally and non-verbally)? Able to accurately convey intent, meaning and purpose to others, and receive accurately from them? Any language based or communication based learning difficulties etc? Comments: Self Awareness/Self Image Question Frequently Sometimes Rarely Feels competent in relation to others? Any persistent self-defeating behaviors? Accurate perception of self in relation to others (over or underplaying strengths)? Any body image problems? How is self esteem? Positive/Robust Moderate/Varies Challenged/Poor/Impaired Comments: Speech/Articulation Question Frequently Sometimes Rarely Problems with volume or clarity of communication when talking? Problems with speech accuracy? Mumbling, muttering, stuttering, other speech problems? Comments: Concrete Cognition Question Frequently Sometimes Rarely Able to recognize the meaning of physical objects? Able to understand how different objects and/or events relate to each other? Understands causality, permanence, etc. Comments: Frontal Cortex Non-verbal Cognition Question Frequently Sometimes Rarely Able to process, plan, sequence and organize information? "Street smart?" Able to understand non-verbal subtle relational interactions? IQ test of performance? Within normal range Above average Below average Not tested Comments: Modulate Reactivity/Impulsivity Question Frequently Sometimes Rarely Able to self regulate when upset? Able to think things through before reacting impulsively? Impulsivity level? Very Low Low Moderate High Very High Comments: Math/Symbolic Cognition Math abilities? Numbers, symbols – able to understand/read numbers and/or symbols with accuracy? Average for Age Range Above Average for Age Range Below Average for Age Range Comments: Reading/Verbal Question Frequently Sometimes Rarely Able to use language verbally and in writing? Verbal sub scales on IQ testing. Within normal range Above average Below average Not tested Comments: Abstract/Reflective Cognition Question Frequently Sometimes Rarely Able to take information from prior experiences and apply it in creative or abstract ways in the present? Level of insight/self awareness? High/Insightful Moderate Low Comments: Values/Beliefs Question Frequently Sometimes Rarely Values, morals? Able to be honest? Take others' needs into consideration when balancing their own needs? Likelihood of engaging in limit-seeking / sanction-seeking behavior Comments: Download as PDF Email Instructions Reset Form
