Nervous System Reset Progress Assessment
Report your own experiences for your care team to review. This form and the AI assistant do not diagnose, treat, or create or adjust a treatment plan. For chest pain, severe breathing difficulty, or immediate danger, call 911 or local emergency services now rather than completing this form.
Patient & Session Information
Client ID
*
Week Number
Submission Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Week
Rate each area from 1 (significant difficulty) to 10 (doing very well).
Stress regulation
Significant difficulty
1
2
3
4
5
6
7
8
9
Doing very well
10
1 is Significant difficulty, 10 is Doing very well
Energy
Significant difficulty
1
2
3
4
5
6
7
8
9
Doing very well
10
1 is Significant difficulty, 10 is Doing very well
Sleep quality
Significant difficulty
1
2
3
4
5
6
7
8
9
Doing very well
10
1 is Significant difficulty, 10 is Doing very well
Mood stability
Significant difficulty
1
2
3
4
5
6
7
8
9
Doing very well
10
1 is Significant difficulty, 10 is Doing very well
Mental clarity
Significant difficulty
1
2
3
4
5
6
7
8
9
Doing very well
10
1 is Significant difficulty, 10 is Doing very well
Focus
Significant difficulty
1
2
3
4
5
6
7
8
9
Doing very well
10
1 is Significant difficulty, 10 is Doing very well
Emotional calmness
Significant difficulty
1
2
3
4
5
6
7
8
9
Doing very well
10
1 is Significant difficulty, 10 is Doing very well
Physical calmness
Significant difficulty
1
2
3
4
5
6
7
8
9
Doing very well
10
1 is Significant difficulty, 10 is Doing very well
Physical recovery
Significant difficulty
1
2
3
4
5
6
7
8
9
Doing very well
10
1 is Significant difficulty, 10 is Doing very well
Overall well-being
Significant difficulty
1
2
3
4
5
6
7
8
9
Doing very well
10
1 is Significant difficulty, 10 is Doing very well
Overall, I feel:
Much Better
Better
About the Same
Slightly Worse
Much Worse
Reported Experiences This Week
Feeling on edge or unusually alert
Never
Rarely
Sometimes
Often
Almost always
Rapid heart rate or racing thoughts
Never
Rarely
Sometimes
Often
Almost always
Muscle tension
Never
Rarely
Sometimes
Often
Almost always
Irritability or restlessness
Never
Rarely
Sometimes
Often
Almost always
Feeling frozen, numb, or disconnected
Never
Rarely
Sometimes
Often
Almost always
Difficulty concentrating
Never
Rarely
Sometimes
Often
Almost always
Sleep disruption
Never
Rarely
Sometimes
Often
Almost always
Difficulty returning to calm
Never
Rarely
Sometimes
Often
Almost always
4. On how many days did you practice your Nervous System Reset exercises?
5. Which reset practices did you use?
Breathwork
Grounding
Bilateral rhythm or movement
Meditation
Mindfulness or body scan
Gentle movement or stretching
Nature or outdoor time
None this week
Other
6. Overall, how effective were your reset practices?
Skip this if you did not use any reset practices this week.
7. How long did it usually take you to return to calm?
Under 5 minutes
5–15 minutes
16–30 minutes
31–60 minutes
More than 60 minutes
I was unable to return to calm
8. What was your biggest trigger or challenge this week?
9. What support would help you next week?
10. Any additional notes for your coach?
Submit
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