NeuroBehavioral Symptom Inventory (NSI) 22 items
(to be completed by a subject under supervision of a trained clinician)


Please rate the following symptomw with regard to how much they have disturbed you:
- first column, at a critical time in the past
- second column, IN THE LAST 2 Weeks.

The purpose of this inventory is to record your symptoms from the distant past and recently.

0 = None - Rarely if ever present; not a problem at all

1 = Mild - Occasionally present, but it does not dirupt by activities; I can usually continue what I'm doing; doesn't really concern me.

2 = Moderate - Often present, occasionally disrupts my activities; I can usually continue what I'm doing with some effort; I fee somewhat concerned

3 = Severe - Frequently present and disrupts activities; I can only do things that are fairly simple or take little effort; I feel I need help

4 = Very Severe - Almost always present and I have been unable to perform at work, school or home due to this problem; I probably cannot function without help.

       DATE:           TIME (24hr): 


INSTRUCTIONS: Below is a list of problems, symptoms, and complaints that people sometimes have in response to stressful experiences. Please read each one carefully, then click the circle to indicate how much you have been bothered by that problem in the past month.


  In the past month, how much were you bothered by:

0

1

2

3

4

  1.  Feeling Dizzy?
  

  

  

  

  

  2.  Loss of balance?
  

  

  

  

  

  3.  Poor coordination, clumsy?
  

  

  

  

  

  4.  Headaches?
  

  

  

  

  

  5.  Nausea?
  

  

  

  

  

  6.  Vision problems, blurring, trouble seeing?
  

  

  

  

  

  7.  Sensitivity to light?
  

  

  

  

  

  8.  Hearing difficulty?
  

  

  

  

  

  9.  Sensitivity to noise?
  

  

  

  

  

 10. Numbness or tingling on parts of my body?
  

  

  

  

  

 11. Change in taste and/or smell?
  

  

  

  

  

 12. Loss of appetite or increased appetite
  

  

  

  

  

 13. Poor concentration, can’t pay attention, easily distracted?
  

  

  

  

  

 14. Forgetfulness, can’t remember things?
  

  

  

  

  

 15. Difficulty making decisions?
  

  

  

  

  

 16. Slowed thinking, difficulty getting organized, can’t finish things?
  

  

  

  

  

 17. Fatigue, loss of energy, getting tired easily?
  

  

  

  

  

 18. Difficulty falling or staying asleep?
  

  

  

  

  

 19. Feeling anxious or tense?
  

  

  

  

  

 20. Feeling depressed or sad?
  

  

  

  

  

 21. Irritability, easily annoyed?
  

  

  

  

  

 22. Poor frustration tolerance, feeling easily overwhelmed by things?
  

  

  

  

  



    

TEXT FOR YOUR RECORDS

NSI  maximum score = 80

0    -  19      normal
20  -  39      mild
40  -  59      moderate
60  -  69      severe
70  -  80      extreme

DATA FILE

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          Last update:  05/12/2020