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C-SARS Evaluation

C-SARS EvaluationAdmin2020-09-30T15:37:31-04:00

Step 1 of 13

7%

Name*
Full Name
Email*

A copy of your responses will be sent to this email.

1. I have difficulty staying focused on something I am reading or a TV program I am watching
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

2. I have difficulty remembering things that happened or what people told me
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

3. I forget what I am supposed to do
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

4. I forget where I put things
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

5. When I am speaking I forget what I was going to say
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

6. I have difficulty planning ahead or making decisions
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

7. I keep doing the same thing even though it does not work
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

8. I do things without thinking
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

9. I have difficulty adjusting to changes
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

10. I tend to be slow in mental or physical tasks
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

11. I have trouble reading someone's facial expression or gestures
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time

12. I have difficulty understanding how another person feels
A. FREQUENCY*
- Rarely
- Sometimes
- Often
- All the time
B. HOW MUCH IT INTERFERES WITH MY LIFE*
- Rarely
- Sometimes
- Often
- All the time
Hidden
Frequency Score
Hidden
Severity Score
Comments
This field is for validation purposes and should be left unchanged.

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