Rate how well you are usually able to use your mental skills in your job/sport and personal daily life. Your answers will be used to design a program for you; thus, it is important that you honestly evaluate your skills. All your information is confidential, but group data may be used anonymously for research. PUT an X on the scale that best describes your usual state. The vertical markers in the center indicate 50% of the time. The first box line is for how you USUALLY feel... . In the second line of boxes, put an X for how you feel during important competitions...
Attention
1: Can’t intensely focus at all
2: Quickly lose focus
3:
x: Focus about half of the time
5: Excellent for some activities
6: Excellent steel trap focus on target all the time
1-Short-term focus: the ability to intensely lock your attention for a moment on an event/task inside your head (thoughts, images) or outside your head(objects, groups, others speaking, etc):
1. Usually feel *
1: Can’t intensely focus at all
6: Excellent steel trap focus on target all the time
1. Important competition *
Can't
Excellent
2-Sustained attention: The ability to maintain sufficient attention across a longer time period to perform or take in and process information ( eg data input, attending to conversations, instructions, etc)
Rate your ability to sustain or keep your attention across time in your job, sport, daily personal life
2. Usually feel
Can't
Excellent
2. Important competition *
Can't
Excellent
3-Busy Brain: Rate your typical state of brain activity( busy brain) while on your job, sport or in daily personal life
3. Usually feel
Can't
Excellent
3. Important competition
Can't
Excellent
Calm(ability to stay calm and in control and/or let go of irrelevant thoughts)
4-Control
4. Usually feel
Can't
Excellent
4. Important competition
Can't
Excellent
5-Letting go
5. Usually feel
Can't
Excellent
5. Important competition
Can't
Excellent
6- Rate your typical Anxiety/worry state while on your job, sport, or in daily personal life.
6. Usually feel
Can't
Excellent
6. Important competition
Can't
Excellent
7- Rate your typical negative/depression state while on your job, sport or in daily personal life state while on your job, sport, or in daily personal life
7. Usually feel
Can't
Excellent
7. Important competition
Can't
Excellent
8-Muscle -tightening or tremor
8. Usually feel
Can't
Excellent
8. Important competition
Can't
Excellent
9-Breathing-breath holding, erratic breathing, or fast breathing when sedentary
9. Usually feel
Can't
Excellent
9. Important competition
Can't
Excellent
10-Heart Racing
10. Usually feel
Can't
Excellent
10. Important competition
Can't
Excellent
11- Sweat more under stress
11. Usually feel
Can't
Excellent
11. Important competition
Can't
Excellent
12-Hands get colder under stress
12. Usually feel
Can't
Excellent
12. Important competition
Can't
Excellent
13-stomach knots during stress
13. Usually feel
Can't
Excellent
13. Important competition
Can't
Excellent
Sleep
14- Rate your typical time to fall asleep
14. Usually feel
Can't
Excellent
14. Important competition
Can't
Excellent
15-Rate your typical experience of night awakening
15. Usually feel
Can't
Excellent
15. Important competition
Can't
Excellent
16-Rate how the quality of your sleep affects the next day
16. Usually feel
Can't
Excellent
16. Important competition
Can't
Excellent
17-Sufficient balanced nutrition
17. Usually feel
Can't
Excellent
18-Use of tobacco, alcohol, drugs
18. Important competition
Can't
Excellent
18. Usually feel
Can't
Excellent
19-Discipline to maintain habits
19. Usually feel
Can't
Excellent
19. Important competition
Can't
Excellent
Belief
20-Firm Belief
20. Usually feel
Can't
Excellent
20. Important competition
Can't
Excellent
21-Commitment/Challenge
21. Usually feel
Can't
Excellent
21. Important competition
Can't
Excellent
22-Coping with adversity
22. Usually feel
Can't
Excellent
22. Important competition
Can't
Excellent
23-social resources/communication/cooperation
23. Usually feel
Can't
Excellent
23. Important competition
Can't
Excellent
24-Problem solving technique
24. Usually feel
Can't
Excellent
24. Important competition
Can't
Excellent
24. Usually feel
Can't
Excellent
Ideal performance /zone
25-Ideal performance preparation: (fitness, competition, coaching, lifestyle, etc.)
25. Usually feel
Can't
Excellent
25. Important competition
Can't
Excellent
26-ideal body performance state: (calm or controlled and able to give best physical performance)
26. Usually feel
Can't
Excellent
26. Important competition
Can't
Excellent
27-Ideal mental performance state: (feel able to do my best)
27. Usually feel
Can't
Excellent
27. Important competition
Can't
Excellent
28. Which one of the following would MOST benefit your performance if it improved? (put a checkmark or X by your choice; only choose one)
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Phone: (604) 220-8866 | 
Monday—Friday: 9:00 AM-7:30 PM
