EJECUTIVE FUNCTIONS ASSESSMENT
INSTRUCTIONS: With this questionnaire, your habitual cognitive style is explored, in
particular, a set of skills that include short-term memory, organization, emotional control,
among others, which act as a "control center" and guide you in solving of everyday tasks. The
questionnaire is divided into sections according to the main executive functions to be
evaluated. Please: read each statement carefully and answer YES or NO according to the
extent to which it frequently applies to you.
EXECUTIVE FUNCTION 1: ATTENTION Y FOCUS ASSESSMENT
Is this a problem?
QUESTIONS
YES NO
1. Does your partner or another significant person in your life
complain that you don’t listen to them?
2. Do you depend on frequent rewards to stay focused on and
complete a project?
3. Do you rely on others to direct you and keep you focused when
you are performing difficult tasks?
4. Do you use substances like coffee, energy drinks, or nicotine to
help you get your work done?
5. Have you been in a relatively high number of car accidents or
near misses because you weren’t paying attention?
6. Do you engage in dangerous, adrenaline-pumping activities to
help you focus clearly?
7. At work, do you find yourself surfing the internet or shopping
online, or do you wear headphones to drown out your
surroundings?
8. Do people in your environment complain that you are
distracting them while they are trying to stay on a task, or that
you’re not paying attention to what’s going on?
9. When you are in groups, do people complain that you are
derailing the discussions by bringing up irrelevant material?
10. Do you find yourself not contributing to meetings because you
don’t hear or fully comprehend what others are saying, or
because you are afraid someone has already covered what you
are thinking?
EXECUTIVE FUNCTIONS ASSESSMENT DR. MIGUEL MARIN TEJEDA
INSTRUCTIONS: Please: read each question carefully and answer YES or NO if it frequently
applies to you (it constitutes an obvious problem).
EXECUTIVE FUNCTION 2: ORGANIZATION & PLANNING ASSESSMENT
Is this a problem?
QUESTIONS
YES NO
1. Do you have multiple calendars, schedulers, and apps to
manage your time, yet use none of them consistently?
2. Do you miss out on opportunities because you forget to follow
up or track important contacts you have made?
3. Do you have a hard time operating technology that requires
following a set of instructions?
4. Do you have difficulty completing household tasks that require
a sequence of steps, such as sorting the laundry, loading the
washer, putting in the soap, transferring clean clothes to the
dryer, putting in the next load, folding the dry laundry, and
putting the clothes away?
5. Do you lose important documents and have a hard time
remembering to renew important licenses and finish related
paperwork?
6. Do you spend a lot of money on late fees for parking tickets,
library books, and bills?
7. Do you still have old phones and charging devices or other
outdated technology that create clutter that interfere with
being able to find items you actually use?
8. Does packing for a trip stress you out because you aren’t sure
what and/or how much to pack and you worry that you will
forget something?
9. Do your friends and family complain that your space -and
maybe your behavior, too- is sloppy?
10. Have you ever accidentally thrown out an important check,
document, or personal item in an impulsive effort to get rid of
a mess quickly?
EXECUTIVE FUNCTIONS ASSESSMENT DR. MIGUEL MARIN TEJEDA
INSTRUCTIONS: Please: read each question carefully and answer YES or NO if it frequently
applies to you (it constitutes an obvious problem).
EXECUTIVE FUNCTION 3: COGNITIVE FLEXIBILITY ASSESSMENT
Is this a problem?
QUESTIONS
YES NO
1. When other people give you feedback for improvements or
changes, do you usually push back or find roadblocks to their
suggestions?
2. Do you frequently argue with the people you live with when you
get home from work because you can't transition out of "work
mode"?
3. Do you have a hard time interacting with others in a way that
doesn't relate to your work life? Fer example, do you often "talk
shop" when you are socializing?
4. Do you get poor performance reviews at work for not being able
to manage multiple projects, even though you get high ratings
for the work you do complete?
5. Do you often resist introducing change into your personal life
and work settings? For example, do you feel that new tools and
technologies will only make your life more difficult?
6. lf you work in a setting where many requests are made of you
or you have to respond to shifting situations as they arise -such
as a medical setting, service industry, or sales job- do you often
get complaints that you aren't fast or responsive enough?
7. Do you get angry with people for interrupting tasks you are
engaged in?
8. Do you find yourself getting frustrated, depressed, angry,
and/or sad when new people come into a social or work-related
group and/or familiar people leave?
9. lf a friend cancels plans fer the day, would you rather do nothing
than find someone else to make plans with?
10. Do people complain that you tend to minimize other people's
ideas and contributions in an effort to get your way?
EXECUTIVE FUNCTIONS ASSESSMENT DR. MIGUEL MARIN TEJEDA
INSTRUCTIONS: Please: read each question carefully and answer YES or NO if it frequently
applies to you (it constitutes an obvious problem).
EXECUTIVE FUNCTION 4: EMOTION REGULATION ASSESSMENT
Is this a problem?
QUESTIONS
YES NO
1. Do you ruminate about friends and family members who hurt
your feelings, and do you hold on to resentment for weeks?
2. lf someone criticizes you, do you act out with anger and/or think
about ways to retaliate?
3. Have you often been told you are too sensitive?
4. lf you have a conflict with a friend, do you imagine worst-case
scenarios and become anxious that they will end the
friendship, even if it was a small matter?
5. lf you don't do as well as you expected on a test or
performance review. do you start feeling worthless and
depressed?
6. lf a friendship ends, do you find it difficult to believe you'll
develop new friendships with others?
7. Have others described you as a "yeller" or screamer"?
8. Do you use drugs or alcohol to calm down after a stressful day?
9. Do you feel that you overreact to events (that is, your reaction
is greater than what a situation calls for), and/or have you
been told that you overreact?
10. Are you a people pleaser who is afraid to say no to
unreasonable requests because you are afraid of rejection?
EXECUTIVE FUNCTIONS ASSESSMENT DR. MIGUEL MARIN TEJEDA
INSTRUCTIONS: Please: read each question carefully and answer YES or NO if it frequently
applies to you (it constitutes an obvious problem).
EXECUTIVE FUNCTION 5: IMPULSE CONTROL
Is this a problem?
QUESTIONS
YES NO
1. Do you often regret risky behaviors that seemed fun at the time
but that you know will have serious or unwanted
consequences?
2. Do you feel you cannot control saying what's on your mind,
sometimes resulting in angry outbursts or sharing personal
information?
3. Do you find your relationships on shaky ground because you
said something without thinking about the impact your words
would have on someone?
4. Have you been in legal trouble for car accidents, tax fraud, or
other risky behaviors?
5. Do you struggle with debt because you buy things you don't
need and /or can't afford on the spur of the moment?
6. Do you indulge in daring activities despite the consequences of
getting caught, such as possessing drugs, using the services of
sex workers, or driving recklessly?
7. When you have an Important deadline, do you find yourself
accepting invitations and/or starting other activities anyway,
knowing that these things will interfere with your ability to
finish your project?
8. Do you skip out on commitments with people if something
more fun or interesting comes up?
9. Have you ever scheduled a trip to get out of town to avoid a
commitment you didn't feel like keeping?
10. Have you ever made a poor business decision because someone
made you an offer that was too good to be true?
EXECUTIVE FUNCTIONS ASSESSMENT DR. MIGUEL MARIN TEJEDA
