Breathing Skills Record

Current Symptoms Self-Report Form

Rate your concentration Weekand
on breathing and counting during the exercise of: your success with relying mostly on your
diaphragm for breathing, on -point scales (where = none and = excellent), after each practice (twice per day).
------- ------- ------- ------- ------- ------- ------- ------- ------- -------
Instructions: Please check the response next to each item that best describes your behavior during the past week.
None Mild Moderate Strong Excellent

Never or
Rarely Sometimes Concentration
Often on Often
Very
Date Practice Breathing and Counting Success With Breathing
Fail to give close attention to details or make careless
1
mistakes in my work

2 Fidget with hands or feet or squirm in seat

Have diculty sustaining my attention in tasks or

3
fun activities

Leave my seat in situations in which seating is

4
expected

5 Dont listen when spoken to directly

6 Feel restless

Dont follow through on instructions and fail to

7
nish work

Have diculty engaging in leisure activities or doing
8
fun things quietly
9 Have diculty organizing tasks and activities

10 Feel on the go or driven by a motor

Avoid, dislike, or am reluctant to engage in work that
11
requires sustained mental eort

12 Talk excessively

13 Lose things necessary for tasks or activities

Blurt out answers before questions have been
14 completed

15 Am easily distracted

16 Have diculty awaiting turn

17 Am forgetful in daily activities

18 Interrupt or intrude on others

From R. A. Barkley & K. R. Murphy (1998), Attention-Decit Hyperactivity Disorder: A clinical workbook (2nd ed.). New York: Guilford Press.

Reprinted with permission.Mastery

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Copyright 2005Oxford
2006 Oxford University
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