Kala Symptom Tracking Worksheet

Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ADHD-CCSP, C-DBT, CCTP

Client: Kala
Date:

Instructions: Rate each symptom from 1–10
1 = minimal | 10 = severe / highly disruptive

Specific Symptom	Rating	Notes / Examples
Reading Comprehension Difficulty	12345678910
Leaving Comfort Zone (Resistance)	1-10
Resistance to Social Interaction	12345678910
Going for a Drive (Avoidance/Anxiety)	1-10
Avoiding Friend Groups	1-10
Going to Church (Avoidance/Distress)	1-10
Anxiety Level	12345678910
Intrusive Memories	12345678910
Quick to Anger / Irritability	1-10
Spatial Awareness Issues	1-10
Use of Headphones to Reduce Overwhelm	1-10
Ability to Regulate Emotions	1-10
Reaction Sensitivity	1-10
Sensitivity to Light & Sound	1-10
Loud / Continuous Noise Sensitivity	1-10
Dropping Objects / Coordination Issues	1-10
Clothing Sensory Issues (e.g., rough textures)	1-10
Nausea	1-10
Headaches	1-10
Sleep Issues	1-10
Panic Attacks	1-10

Total Score: 0
Average: 0
Severity: -

Calculate Score

---