Master Hemispheric Checklist

Name

First NameLast Name

Date of Birth

MonthDayYear

Please check the appropriate box in "Start of Program".

Motor characteristics of a right brain delay

Clumsiness and an odd posture

Start of program4 weeks8 weeks12 weeks

Poor coordination

Start of program4 weeks8 weeks12 weeks

Not athletically inclined and has no interest in popular childhood participation sports

Start of program4 weeks8 weeks12 weeks

Low muscle tone - muscles seem kind of floppy

Start of program4 weeks8 weeks12 weeks

Poor gross motor skills, such as difficulty learning to ride a bike and/or run and/or walks oddly

Start of program4 weeks8 weeks12 weeks

Repetitive/sterotyped motor mannerisms (spins in circles/flaps arms)

Start of program4 weeks8 weeks12 weeks

Fidgets excessively

Start of program4 weeks8 weeks12 weeks

Poor eye contact

Start of program4 weeks8 weeks12 weeks

Walks or walked on toes when younger

Start of program4 weeks8 weeks12 weeks

TOTAL:

Motor characteristics of a left brain delay

Fine motor problems (poor or slow handwriting)

Start of program4 weeks8 weeks12 weeks

Difficulty with fine motor skills, such as buttoning a shirt

Start of program4 weeks8 weeks12 weeks

Poor or immature hand grip when writing

Start of program4 weeks8 weeks12 weeks

Tends to write very large for age or grade level

Start of program4 weeks8 weeks12 weeks

Stumbles over words when fatigued

Start of program4 weeks8 weeks12 weeks

Exhibited delay in crawling, standing, and/or walking

Start of program4 weeks8 weeks12 weeks

Loves sports and is good at them

Start of program4 weeks8 weeks12 weeks

Good muscle tone

Start of program4 weeks8 weeks12 weeks

Poor drawing skills

Start of program4 weeks8 weeks12 weeks

Difficulty learning to play music

Start of program4 weeks8 weeks12 weeks

Likes to fix things with the hands and is interested in anything mechanical

Start of program4 weeks8 weeks12 weeks

Difficulty planning and coordinating body movements

Start of program4 weeks8 weeks12 weeks

TOTAL:

Sensory characteristics of a right brain delay

Poor spatial orientation - bumps into things often

Start of program4 weeks8 weeks12 weeks

Sensitivity to sound

Start of program4 weeks8 weeks12 weeks

Confusion when asked to point to different body parts

Start of program4 weeks8 weeks12 weeks

Poor sense of balance

Start of program4 weeks8 weeks12 weeks

High threshold for pain - doesn't cry when gets a cut

Start of program4 weeks8 weeks12 weeks

Likes to spin, go on rides, swing, etc. - anything with motion

Start of program4 weeks8 weeks12 weeks

Touches things compulsively

Start of program4 weeks8 weeks12 weeks

A girl interested in makeup or jewelry

Start of program4 weeks8 weeks12 weeks

Does not like the feel of clothing on arms or legs; pulls clothes off

Start of program4 weeks8 weeks12 weeks

Doesn't like being touched and doesn't like to touch things

Start of program4 weeks8 weeks12 weeks

Incessantly smells everything

Start of program4 weeks8 weeks12 weeks

Prefers bland foods

Start of program4 weeks8 weeks12 weeks

Does not notice strong smells, such as burning wood, popcorn, or cookies baking in the oven

Start of program4 weeks8 weeks12 weeks

Avoid foods because of the way it looks

Start of program4 weeks8 weeks12 weeks

Hates having to eat and is not even interested in sweets

Start of program4 weeks8 weeks12 weeks

Extremely picky eater

Start of program4 weeks8 weeks12 weeks

TOTAL:

Sensory characteristics of a left brain delay

Doesn't seem to have many sensory issues or problems, such as a sensitivity to sound

Start of program4 weeks8 weeks12 weeks

Has good spatial awareness

Start of program4 weeks8 weeks12 weeks

Has good sense of balance

Start of program4 weeks8 weeks12 weeks

Eats just about anything

Start of program4 weeks8 weeks12 weeks

Has a normal to above-average sense of taste and smell

Start of program4 weeks8 weeks12 weeks

Likes to be hugged and held

Start of program4 weeks8 weeks12 weeks

Does not have an oddities concerning clothing

Start of program4 weeks8 weeks12 weeks

Has auditory processing problems

Start of program4 weeks8 weeks12 weeks

Seems to not hear well, although hearing tests are normal

Start of program4 weeks8 weeks12 weeks

Delay in speaking was attributed to ear infections

Start of program4 weeks8 weeks12 weeks

Gets motion sick and has other motion sickness issues

Start of program4 weeks8 weeks12 weeks

Is not undersensitive or oversensitive to pain

Start of program4 weeks8 weeks12 weeks

TOTAL:

Emotional characteristics of a right brain deficiency

Spontaneously cries and/or laughs and has sudden outbursts of anger or fear

Start of program4 weeks8 weeks12 weeks

Worries a lot and has several phobias

Start of program4 weeks8 weeks12 weeks

Holds onto past "hurts"

Start of program4 weeks8 weeks12 weeks

Has sudden emotional outbursts that appear overreactive and inappropriate to the situation

Start of program4 weeks8 weeks12 weeks

Experiences panic and/or anxiety attacks

Start of program4 weeks8 weeks12 weeks

Sometimes displays dark or violent thoughts

Start of program4 weeks8 weeks12 weeks

Face lacks expression; doesn't exhibit much body language

Start of program4 weeks8 weeks12 weeks

Too uptight; cannot seem to loosen up

Start of program4 weeks8 weeks12 weeks

Lacks empathy and feelings for others

Start of program4 weeks8 weeks12 weeks

Lacks emotional reciprocity

Start of program4 weeks8 weeks12 weeks

Often seems fearless and is a risk taker

Start of program4 weeks8 weeks12 weeks

TOTAL:

Emotional characteristics of a left brain deficiency

Overly happy and affectionate; loves to hug and kiss

Start of program4 weeks8 weeks12 weeks

Frequently moody and irritable

Start of program4 weeks8 weeks12 weeks

Loves doing new or different things but gets bored easily

Start of program4 weeks8 weeks12 weeks

Lacks motivation

Start of program4 weeks8 weeks12 weeks

Withdrawn and shy

Start of program4 weeks8 weeks12 weeks

Excessively cautious, pessimistic, or negative

Start of program4 weeks8 weeks12 weeks

Doesn't seem to get any pleasure out of life

Start of program4 weeks8 weeks12 weeks

Socially withdrawn

Start of program4 weeks8 weeks12 weeks

Cries easily; feelings get hurt easily

Start of program4 weeks8 weeks12 weeks

Seems to be in touch with own feelings; reads people's emotions well

Start of program4 weeks8 weeks12 weeks

Gets embarrassed easily

Start of program4 weeks8 weeks12 weeks

Very sensitive to what others think about him or her

Start of program4 weeks8 weeks12 weeks

TOTAL:

Behavioral characteristics of a right brain delay

Logical thinker

Start of program4 weeks8 weeks12 weeks

Often misses the gist of a story

Start of program4 weeks8 weeks12 weeks

Always the last to get a joke

Start of program4 weeks8 weeks12 weeks

Gets stuck in set behavior; can't let it go

Start of program4 weeks8 weeks12 weeks

Lacks social tact and/or is antisocial and/or socially isolated

Start of program4 weeks8 weeks12 weeks

Poor time management; is always late

Start of program4 weeks8 weeks12 weeks

Disorganized

Start of program4 weeks8 weeks12 weeks

Has a problem paying attention

Start of program4 weeks8 weeks12 weeks

Is hyperactive and/or impulsive

Start of program4 weeks8 weeks12 weeks

Has obsessive thoughts or behaviors

Start of program4 weeks8 weeks12 weeks

Argues all the time and is generally uncooperative

Start of program4 weeks8 weeks12 weeks

Exhibits signs of an eating disorder

Start of program4 weeks8 weeks12 weeks

Failed to thrive as an infant

Start of program4 weeks8 weeks12 weeks

Mimics sounds or words repeatedly without really understanding the meaning

Start of program4 weeks8 weeks12 weeks

Appears bored, aloof, and abrupt

Start of program4 weeks8 weeks12 weeks

Considered strange by other children

Start of program4 weeks8 weeks12 weeks

Inability to form friendships

Start of program4 weeks8 weeks12 weeks

Has difficulty sharing enjoyment, interests, or achievements with other people

Start of program4 weeks8 weeks12 weeks

Inappropriately giddy or silly

Start of program4 weeks8 weeks12 weeks

Acts inappropriately in social situations

Start of program4 weeks8 weeks12 weeks

Talks incessantly and asks the same question repetitively

Start of program4 weeks8 weeks12 weeks

Has no or little joint attention, such as the need to point to an object to get your attention

Start of program4 weeks8 weeks12 weeks

Didn't look at self in mirror as toddler

Start of program4 weeks8 weeks12 weeks

TOTAL:

Behavioral characteristics of a left brain delay

Procrastinates

Start of program4 weeks8 weeks12 weeks

Is extremely shy, especially around strangers

Start of program4 weeks8 weeks12 weeks

Is very good at nonverbal communication

Start of program4 weeks8 weeks12 weeks

Is well liked by other children and teachers

Start of program4 weeks8 weeks12 weeks

Does not have any behavioral problems in school

Start of program4 weeks8 weeks12 weeks

Understands social rules

Start of program4 weeks8 weeks12 weeks

Has poor self-esteem

Start of program4 weeks8 weeks12 weeks

Hates doing homework

Start of program4 weeks8 weeks12 weeks

Is very good at social interaction

Start of program4 weeks8 weeks12 weeks

Makes good eye contact

Start of program4 weeks8 weeks12 weeks

Likes to be around people and enjoys social activities, such as going to parties

Start of program4 weeks8 weeks12 weeks

Doesn't like to go to sleepovers

Start of program4 weeks8 weeks12 weeks

Is not good at following routines

Start of program4 weeks8 weeks12 weeks

Can't follow multiple-step directions

Start of program4 weeks8 weeks12 weeks

Is in touch with own feelings

Start of program4 weeks8 weeks12 weeks

Jumps to conclusions

Start of program4 weeks8 weeks12 weeks

TOTAL:

Behavioral characteristics of a right brain delay

Poor math reasoning (word problems, geometry, algebra)

Start of program4 weeks8 weeks12 weeks

Poor reading comprehension and pragmatic skills

Start of program4 weeks8 weeks12 weeks

Misses the big picture

Start of program4 weeks8 weeks12 weeks

Very analytical

Start of program4 weeks8 weeks12 weeks

Likes "slapstick" or obvious physical humor

Start of program4 weeks8 weeks12 weeks

Is very good at finding mistakes (spelling)

Start of program4 weeks8 weeks12 weeks

Takes everything literally

Start of program4 weeks8 weeks12 weeks

Doesn't always reach a conclusion when speaking

Start of program4 weeks8 weeks12 weeks

Started speaking early

Start of program4 weeks8 weeks12 weeks

Has tested for a high IQ, but scores in the whole spectrum; or IQ is above normal in verbal ability and below average in performance abilities

Start of program4 weeks8 weeks12 weeks

Was an early word reader

Start of program4 weeks8 weeks12 weeks

Is interested in unusual topics

Start of program4 weeks8 weeks12 weeks

Learns in a rote "memorizing" manner

Start of program4 weeks8 weeks12 weeks

Learns extraordinary amounts of specific facts about a subject

Start of program4 weeks8 weeks12 weeks

Is impatient

Start of program4 weeks8 weeks12 weeks

Speaks in a monotone; has little voice inflection

Start of program4 weeks8 weeks12 weeks

Is a poor nonverbal communicator

Start of program4 weeks8 weeks12 weeks

Doesn't like loud noises (like fireworks)

Start of program4 weeks8 weeks12 weeks

Speaks out loud regarding what he or she is thinking

Start of program4 weeks8 weeks12 weeks

Talks "in your face" - is a space invader

Start of program4 weeks8 weeks12 weeks

Good reader but does not enjoy reading

Start of program4 weeks8 weeks12 weeks

Analytical; led by logic

Start of program4 weeks8 weeks12 weeks

Follows rules without questioning them

Start of program4 weeks8 weeks12 weeks

Good at keeping track of time

Start of program4 weeks8 weeks12 weeks

Easily memorizes spelling and mathematical formulas

Start of program4 weeks8 weeks12 weeks

Enjoys observing rather than participating

Start of program4 weeks8 weeks12 weeks

Would rather read an instruction manual before trying something new

Start of program4 weeks8 weeks12 weeks

Math was often the first academic subject that became a problem

Start of program4 weeks8 weeks12 weeks

TOTAL:

Academic characteristics of a left brain delay

Very good at big picture skills

Start of program4 weeks8 weeks12 weeks

Is an intuitive thinker and is led by feelings

Start of program4 weeks8 weeks12 weeks

Good at abstract "free" association

Start of program4 weeks8 weeks12 weeks

Poor analytical skills

Start of program4 weeks8 weeks12 weeks

Very visual; loves images and patterns

Start of program4 weeks8 weeks12 weeks

Constantly questions why you're doing something or why rules exist

Start of program4 weeks8 weeks12 weeks

Has poor sense of time

Start of program4 weeks8 weeks12 weeks

Enjoys touching and feeling actual objects

Start of program4 weeks8 weeks12 weeks

Has trouble prioritizing

Start of program4 weeks8 weeks12 weeks

Is unlikely to read instructions before trying something new

Start of program4 weeks8 weeks12 weeks

Is naturally creative, but needs to work hard to develop full potential

Start of program4 weeks8 weeks12 weeks

Would rather do things instead of observe

Start of program4 weeks8 weeks12 weeks

Uses good voice inflection when speaking

Start of program4 weeks8 weeks12 weeks

Misreads or omits common small words

Start of program4 weeks8 weeks12 weeks

Has difficulty saying long words

Start of program4 weeks8 weeks12 weeks

Reads very slowly and laboriously

Start of program4 weeks8 weeks12 weeks

Had difficulty naming colors, objects, and letters as a toddler

Start of program4 weeks8 weeks12 weeks

Needs to hear or see concepts many times in order to learn them

Start of program4 weeks8 weeks12 weeks

Has shown a downward trend in achievement test scores or school performance

Start of program4 weeks8 weeks12 weeks

Schoolwork is inconsistent

Start of program4 weeks8 weeks12 weeks

Was a late talker

Start of program4 weeks8 weeks12 weeks

Has difficulty pronouncing words (poor with phonics)

Start of program4 weeks8 weeks12 weeks

Had difficulty learning the alphabet, nursery rhymes, or songs when young

Start of program4 weeks8 weeks12 weeks

Has difficulty finishing homework or finishing a conversation

Start of program4 weeks8 weeks12 weeks

Acts before thinking and makes careless mistakes

Start of program4 weeks8 weeks12 weeks

Daydreams a lot

Start of program4 weeks8 weeks12 weeks

Has difficulty sequencing events in the proper order

Start of program4 weeks8 weeks12 weeks

Often writes letters backwards

Start of program4 weeks8 weeks12 weeks

Is poor at basic math skills

Start of program4 weeks8 weeks12 weeks

Has poor memorization skills

Start of program4 weeks8 weeks12 weeks

Has poor academic ability

Start of program4 weeks8 weeks12 weeks

Has an IQ lower than expected and verbal scores are lower than nonverbal scores

Start of program4 weeks8 weeks12 weeks

Performs poorly on verbal tests

Start of program4 weeks8 weeks12 weeks

Needs to be told to do something several times before acting on it

Start of program4 weeks8 weeks12 weeks

Stutters or stuttered when younger

Start of program4 weeks8 weeks12 weeks

Is a poor speller

Start of program4 weeks8 weeks12 weeks

Doesn't read directions well

Start of program4 weeks8 weeks12 weeks

TOTAL:

Common immune characteristics of a right brain delay

Has lots of allergies

Start of program4 weeks8 weeks12 weeks

Rarely gets colds and infections

Start of program4 weeks8 weeks12 weeks

Has had eczema or asthma

Start of program4 weeks8 weeks12 weeks

Skin has little white bumps, especially on the back of the arms

Start of program4 weeks8 weeks12 weeks

Displays erratic behavior - good one day, bad the next

Start of program4 weeks8 weeks12 weeks

Craves certain foods, especially dairy and wheat products

Start of program4 weeks8 weeks12 weeks

TOTAL:

Common immune characteristics of a left brain delay

Gets chronic ear infections

Start of program4 weeks8 weeks12 weeks

Prone to benign tumors or cysts

Start of program4 weeks8 weeks12 weeks

Has taken antibiotics more than 10-15 times before the age of 10

Start of program4 weeks8 weeks12 weeks

Has had tubes put in the ears

Start of program4 weeks8 weeks12 weeks

Catches colds frequently

Start of program4 weeks8 weeks12 weeks

No allergies

Start of program4 weeks8 weeks12 weeks

TOTAL:

Autonomic characteristics of a right brain delay

Problems with bowels, such as constipation and diarrhea

Start of program4 weeks8 weeks12 weeks

Has a rapid heart rate and/or high blood pressure for age

Start of program4 weeks8 weeks12 weeks

Appears bloated, especially after meals, and often complains of stomach pains

Start of program4 weeks8 weeks12 weeks

Has body odor

Start of program4 weeks8 weeks12 weeks

Sweats a lot

Start of program4 weeks8 weeks12 weeks

Hands are always moist and clammy

Start of program4 weeks8 weeks12 weeks

TOTAL:

Autonomic characteristics of a left brain delay

Has a bedwetting problem

Start of program4 weeks8 weeks12 weeks

Has or had an irregular heartbeat, such as an arrhythmia or a heart murmur

Start of program4 weeks8 weeks12 weeks

TOTAL:

Taking the Total

Start of program 4 weeks 8 weeks 12 weeks

Right brain total:

Left brain total:

Grand total:

Hemisphericity (side of weakness)

Motor characteristics of a right brain delay

Sensory characteristics of a right brain delay

Emotional characteristics of a right brain deficiency

Behavioral characteristics of a right brain delay

Academic characteristics of a right brain delay

Common immune characteristics of a right brain delay

Autoimmune characteristics of a right brain delay

Motor characteristics of a left brain delay

Sensory characteristics of a left brain delay

Emotional characteristics of a left brain deficiency

Behavioral characteristics of a left brain delay

Academic characteristics of a left brain delay

Common immune characteristics of a left brain delay

Autonomic characteristics of a left brain delay