Brain Region Localization Form INSTRUCTIONS:The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please answer every question, do not skip any questions. Follow the 0 to 4 key, and select which best fits for all of your answers.Key0 = I never have symptoms (0% of the time)1 = I rarely have symptoms (Less than 25% of the time)2 = I often have symptoms (Half of the time)3 = I frequently have symptoms (75% of the time)4 = I always have symptoms (100% of the time)Name* First Last Date* Frontal lobe Prefrontal, Dorsolateral and Orbitofronta (Areas 9, 10, 11, and 12)Difficulty with restraint and controlling impulses or desires*01234Emotional instability (lability)*01234Difficulty planning and organizing*01234Difficulty making decisions*01234Lack of motivation, enthusiasm,interest and drive (apathetic)*01234Difficulty getting a sound or melody out of your thoughts (Perseveration)*01234Constantly repeat events or thoughts with difficulty letting go*01234Difficulty initiating and finishing tasks*01234Episodes of depression*01234Mental fatigue*01234Decrease in attention span*01234Difficulty staying focused and concentrating for extended periods of time*01234Difficulty with creativity, imagination, and intuition*01234Difficulty in appreciating art and music*01234Difficulty with analytical thought*01234Difficulty with math, number skills and time consciousness*01234Difficulty taking ideas, actions, and words and putting them in a linear sequence*01234Frontal Lobe Precentral and Supplementary Motor Areas (Area 4 and 6)Initiating movements with your arm or leg has become more difficult*01234Feeling of arm or leg heaviness, especially when tired*01234Increased muscle tightness in your arm or leg*01234Reduced muscle endurance in your arm or leg*01234Noticeable difference in your muscle function or strength from one side to the other*01234Noticeable difference in your muscle tightness from one side to the other*01234Frontal Lobe Broca’s Motor Speech Area (Area 44 and 45)Difficulty producing words verbally, especially when fatigued*01234Find the actual act of speaking difficult at times*01234Notice word pronunciation and speaking fluency change at times*01234Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3,1,2 and 7)Difficulty in perception of position of limbs*01234Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall*01234Frequently bumping body or limbs into the wall or objects accidently*01234Reoccurring injury in the same body part or side of the body*01234Hypersensitivities to touch or pain perception*01234Parietal Inferior Lobule (Area 39 and 40)Right/left confusion*01234Difficulty with math calculations*01234Difficulty finding words*01234Difficulty with writing*01234Difficulty recognizing symbols or shapes*01234Difficulty with simple drawings*01234Difficulty interpreting maps*01234Temporal Lobe Auditory Cortex (Areas 41, 42)Reduced function in overall hearing*01234Difficulty interpreting speech with background or scatter noise*01234Difficulty comprehending language without perfect pronunciation*01234Need to look at someone’s mouth when they are speaking to understand what they are saying*01234Difficulty in localizing sound*01234Dislike of left predictable rhythmic, repeated tempo and beat music*01234Dislike of non-predictable rhythmic with multiple instruments*01234Noticeable ear preference when using your phone*01234Temporal Lobe Auditory Association Cortex (Area 22)Difficulty comprehending meaning of spoken words*01234Tend toward monotone speech without fluctuations or emotions*01234Medial Temporal lobe and HippocampusMemory less efficient*01234Memory loss that impacts daily activities*01234Confusion about dates, the passage of time, or place*01234Difficulty remembering events*01234Misplacement of things and difficulty retracing steps*01234Difficulty with memory of locations (addresses)*01234Difficulty with visual memory*01234Always forgetting where you put items such as keys, wallet, phone, etc.*01234Difficulty remembering faces*01234Difficulty remembering names with faces*01234Difficulty with remembering words*01234Difficulty remembering numbers*01234Difficulty remembering to stay or be on time (reduced left)*01234Occipital Lobe (Area, 17, 18, and 19)Difficulty in discriminating similar shades of color*01234Dullness of colors in visual field*01234Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach out for objects*01234Floater or halos in visual field*01234Cerebellum - SpinocerebellumDifficulty with balance, or balance that is worse on one side*01234A need to hold the handrail or watch each step carefully when going down stairs*01234Feeling unsteady and prone to falling in the dark*01234Proness to sway to one side when walking or standing*01234Cerebellum - CerebrocerebellumRecent clumsiness in hands*01234Recent clumsiness in feet or frequent tripping*01234A slight hand shake when reaching for something at the end of movement*01234Cerebellum - VestibulocerebellumEpisodes of dizziness or disorientation*01234Back muscles that tire quickly when standing or walking*01234Chronic neck or back muscle tightness*01234Nausea, car sickness, or sea sickness*01234Feeling of disorientation or shifting of the environment Crowded places cause anxiety*01234Basal Ganglia Direct PathwaySlowness in movements*01234Stiffness in your muscles (not joints) that goes away when you move*01234Cramping of hands when writing*01234A stooped posture when walking*01234Voice has become softer*01234Facial expression changed leading people to frequently ask if you are upset or angry*01234Basal Ganglia Indirect PathwayUncontrollable muscle movements*01234Intense need to clear your throat regularly or contract a group of muscles*01234Obsessive compulsive tendencies*01234Constant nervousness and restless mind*01234Autonomic Reduced Parasympathetic ActivityDry mouth or eyes*01234Difficulty swallowing supplements or large bites of food*01234Slow bowel movements and tendency for constipation*01234Chronic digestive complaints*01234Bowel or bladder incontinence resulting in staining your underwear*01234Autonomic Increased Sympathetic ActivityTendency for anxiety*01234Easily startled*01234Difficulty relaxing*01234Sensitive to bright or flashing lights*01234Episodes of racing heart*01234Difficulty sleeping*01234SymptomsBlurred vision at distance*01234Blurred vision at near*01234Difficulty changing focus from distance to near, or near to distance*01234Words jump or move around when reading*01234Eyes ache*01234Pain with eye movement*01234Pain in or around eyes*01234Loss of vision/tunnel vision*01234Flashes, Floaters, other*01234Red, burning, itchy watery eyes*01234Short attention span for reading or writing*01234Loss of interest/concentration when doing close work*01234Movement of objects in the background is bothersome*01234Patterned wallpaper or carpets are bothersome*01234INSTRUCTIONS:The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please select yes or noHave you ever been diagnosed with a seizure disorder?*YesNoHave you ever been told that you seemed frozen, absent, or tuned out at times without any recollection of the event?*YesNoHave you ever experienced sudden muscle stiffness and rigidity throughout your body?*YesNoHave you ever experienced sudden muscle jerks throughout your body?*YesNoHave you ever experienced a total loss of your muscle tone that lead to loss of control of your muscles or a fall?*YesNoHave you ever been told that you stare into space while you’re lip smacking, chewing, or fidgeting that you are not aware of?*YesNoDo you ever experience sudden emotional responses such as anxiety, sadness, cry, or laugh for no real reason?*YesNoDo you ever experience sudden racing heart rate, sudden loss of bladder function, intestinal spasm, respiration, sweating, or any other sudden changes of function?*YesNoDo you ever experience sudden involuntary muscle contractures or jerks in any individual parts of your limbs or face?*YesNoDo you ever experience sudden involuntary head rotation and your eyes move forcefully to one side?*YesNoDo you ever experience sudden involuntary shift in your eyes to the side or upwards?*YesNoDo you ever experience sudden vocalization of random words or notice a sudden inability to speak?*YesNoDo you ever experience any spontaneous sensations of tingling, pins and needles” numbness, coldness, burning or other random sensations in any region of your body?*YesNoDo you ever experience a ringing sensation in your ears (tinnitus), sounds, or voices spontaneously?*YesNoDo you ever experience spontaneous perception of smells such as burning rubber, foul smells, or other odors without finding the source of the odor?*YesNoDo you ever experience flashing lights, stars, or jagged lines in your visual field?*YesNoEmailThis field is for validation purposes and should be left unchanged.
