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Academic Indications Questionnaire
Academic Indications Questionnaire
Please rate yourself on each of the symptoms listed below using the following scale. If there are questions not applicable or not observed, write “NA.” All information is secure through our HIPPA compliant database.
15Questions
Academic Questionnaire
  • 1
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  • 2
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
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  • 3
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
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  • 4
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
    1 of 6
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  • 5
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
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  • 6
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
    1 of 5
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  • 7
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
    1 of 4
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  • 8
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
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  • 9
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
    1 of 2
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  • 10
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
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  • 11
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
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  • 12
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
    1 of 8
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  • 13
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
    1 of 6
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  • 14
    0 - Never 1 - Rarely 2 - Occasionally 3 - Frequently 4 - Very Frequently NA - Not Applicable/Not Observed
    1 of 18
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  • 15
    TextSizeCreated with Sketch.
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    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
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