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* MM slash DD slash YYYY Frontal lobe Prefrontal, Dorsolateral and Orbitofronta (Areas 9, 10, 11, and 12)Difficulty with restraint and controlling impulses or desires* 0 1 2 3 4 Emotional instability (lability)* 0 1 2 3 4 Difficulty planning and organizing* 0 1 2 3 4 Difficulty making decisions* 0 1 2 3 4 Lack of motivation, enthusiasm,interest and drive (apathetic)* 0 1 2 3 4 Difficulty getting a sound or melody out of your thoughts (Perseveration)* 0 1 2 3 4 Constantly repeat events or thoughts with difficulty letting go* 0 1 2 3 4 Difficulty initiating and finishing tasks* 0 1 2 3 4 Episodes of depression* 0 1 2 3 4 Mental fatigue* 0 1 2 3 4 Decrease in attention span* 0 1 2 3 4 Difficulty staying focused and concentrating for extended periods of time* 0 1 2 3 4 Difficulty with creativity, imagination, and intuition* 0 1 2 3 4 Difficulty in appreciating art and music* 0 1 2 3 4 Difficulty with analytical thought* 0 1 2 3 4 Difficulty with math, number skills and time consciousness* 0 1 2 3 4 Difficulty taking ideas, actions, and words and putting them in a linear sequence* 0 1 2 3 4 Frontal Lobe Precentral and Supplementary Motor Areas (Area 4 and 6)Initiating movements with your arm or leg has become more difficult* 0 1 2 3 4 Feeling of arm or leg heaviness, especially when tired* 0 1 2 3 4 Increased muscle tightness in your arm or leg* 0 1 2 3 4 Reduced muscle endurance in your arm or leg* 0 1 2 3 4 Noticeable difference in your muscle function or strength from one side to the other* 0 1 2 3 4 Noticeable difference in your muscle tightness from one side to the other* 0 1 2 3 4 Frontal Lobe Broca’s Motor Speech Area (Area 44 and 45)Difficulty producing words verbally, especially when fatigued* 0 1 2 3 4 Find the actual act of speaking difficult at times* 0 1 2 3 4 Notice word pronunciation and speaking fluency change at times* 0 1 2 3 4 Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3,1,2 and 7)Difficulty in perception of position of limbs* 0 1 2 3 4 Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall* 0 1 2 3 4 Frequently bumping body or limbs into the wall or objects accidently* 0 1 2 3 4 Reoccurring injury in the same body part or side of the body* 0 1 2 3 4 Hypersensitivities to touch or pain perception* 0 1 2 3 4 Parietal Inferior Lobule (Area 39 and 40)Right/left confusion* 0 1 2 3 4 Difficulty with math calculations* 0 1 2 3 4 Difficulty finding words* 0 1 2 3 4 Difficulty with writing* 0 1 2 3 4 Difficulty recognizing symbols or shapes* 0 1 2 3 4 Difficulty with simple drawings* 0 1 2 3 4 Difficulty interpreting maps* 0 1 2 3 4 Temporal Lobe Auditory Cortex (Areas 41, 42)Reduced function in overall hearing* 0 1 2 3 4 Difficulty interpreting speech with background or scatter noise* 0 1 2 3 4 Difficulty comprehending language without perfect pronunciation* 0 1 2 3 4 Need to look at someone’s mouth when they are speaking to understand what they are saying* 0 1 2 3 4 Difficulty in localizing sound* 0 1 2 3 4 Dislike of left predictable rhythmic, repeated tempo and beat music* 0 1 2 3 4 Dislike of non-predictable rhythmic with multiple instruments* 0 1 2 3 4 Noticeable ear preference when using your phone* 0 1 2 3 4 Temporal Lobe Auditory Association Cortex (Area 22)Difficulty comprehending meaning of spoken words* 0 1 2 3 4 Tend toward monotone speech without fluctuations or emotions* 0 1 2 3 4 Medial Temporal lobe and HippocampusMemory less efficient* 0 1 2 3 4 Memory loss that impacts daily activities* 0 1 2 3 4 Confusion about dates, the passage of time, or place* 0 1 2 3 4 Difficulty remembering events* 0 1 2 3 4 Misplacement of things and difficulty retracing steps* 0 1 2 3 4 Difficulty with memory of locations (addresses)* 0 1 2 3 4 Difficulty with visual memory* 0 1 2 3 4 Always forgetting where you put items such as keys, wallet, phone, etc.* 0 1 2 3 4 Difficulty remembering faces* 0 1 2 3 4 Difficulty remembering names with faces* 0 1 2 3 4 Difficulty with remembering words* 0 1 2 3 4 Difficulty remembering numbers* 0 1 2 3 4 Difficulty remembering to stay or be on time (reduced left)* 0 1 2 3 4 Occipital Lobe (Area, 17, 18, and 19)Difficulty in discriminating similar shades of color* 0 1 2 3 4 Dullness of colors in visual field* 0 1 2 3 4 Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach out for objects* 0 1 2 3 4 Floater or halos in visual field* 0 1 2 3 4 Cerebellum - SpinocerebellumDifficulty with balance, or balance that is worse on one side* 0 1 2 3 4 A need to hold the handrail or watch each step carefully when going down stairs* 0 1 2 3 4 Feeling unsteady and prone to falling in the dark* 0 1 2 3 4 Proness to sway to one side when walking or standing* 0 1 2 3 4 Cerebellum - CerebrocerebellumRecent clumsiness in hands* 0 1 2 3 4 Recent clumsiness in feet or frequent tripping* 0 1 2 3 4 A slight hand shake when reaching for something at the end of movement* 0 1 2 3 4 Cerebellum - VestibulocerebellumEpisodes of dizziness or disorientation* 0 1 2 3 4 Back muscles that tire quickly when standing or walking* 0 1 2 3 4 Chronic neck or back muscle tightness* 0 1 2 3 4 Nausea, car sickness, or sea sickness* 0 1 2 3 4 Feeling of disorientation or shifting of the environment Crowded places cause anxiety* 0 1 2 3 4 Basal Ganglia Direct PathwaySlowness in movements* 0 1 2 3 4 Stiffness in your muscles (not joints) that goes away when you move* 0 1 2 3 4 Cramping of hands when writing* 0 1 2 3 4 A stooped posture when walking* 0 1 2 3 4 Voice has become softer* 0 1 2 3 4 Facial expression changed leading people to frequently ask if you are upset or angry* 0 1 2 3 4 Basal Ganglia Indirect PathwayUncontrollable muscle movements* 0 1 2 3 4 Intense need to clear your throat regularly or contract a group of muscles* 0 1 2 3 4 Obsessive compulsive tendencies* 0 1 2 3 4 Constant nervousness and restless mind* 0 1 2 3 4 Autonomic Reduced Parasympathetic ActivityDry mouth or eyes* 0 1 2 3 4 Difficulty swallowing supplements or large bites of food* 0 1 2 3 4 Slow bowel movements and tendency for constipation* 0 1 2 3 4 Chronic digestive complaints* 0 1 2 3 4 Bowel or bladder incontinence resulting in staining your underwear* 0 1 2 3 4 Autonomic Increased Sympathetic ActivityTendency for anxiety* 0 1 2 3 4 Easily startled* 0 1 2 3 4 Difficulty relaxing* 0 1 2 3 4 Sensitive to bright or flashing lights* 0 1 2 3 4 Episodes of racing heart* 0 1 2 3 4 Difficulty sleeping* 0 1 2 3 4 SymptomsBlurred vision at distance* 0 1 2 3 4 Blurred vision at near* 0 1 2 3 4 Difficulty changing focus from distance to near, or near to distance* 0 1 2 3 4 Words jump or move around when reading* 0 1 2 3 4 Eyes ache* 0 1 2 3 4 Pain with eye movement* 0 1 2 3 4 Pain in or around eyes* 0 1 2 3 4 Loss of vision/tunnel vision* 0 1 2 3 4 Flashes, Floaters, other* 0 1 2 3 4 Red, burning, itchy watery eyes* 0 1 2 3 4 Short attention span for reading or writing* 0 1 2 3 4 Loss of interest/concentration when doing close work* 0 1 2 3 4 Movement of objects in the background is bothersome* 0 1 2 3 4 Patterned wallpaper or carpets are bothersome* 0 1 2 3 4 INSTRUCTIONS: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?* Yes No Have you ever been told that you seemed frozen, absent, or tuned out at times without any recollection of the event?* Yes No Have you ever experienced sudden muscle stiffness and rigidity throughout your body?* Yes No Have you ever experienced sudden muscle jerks throughout your body?* Yes No Have you ever experienced a total loss of your muscle tone that lead to loss of control of your muscles or a fall?* Yes No Have you ever been told that you stare into space while you’re lip smacking, chewing, or fidgeting that you are not aware of?* Yes No Do you ever experience sudden emotional responses such as anxiety, sadness, cry, or laugh for no real reason?* Yes No Do you ever experience sudden racing heart rate, sudden loss of bladder function, intestinal spasm, respiration, sweating, or any other sudden changes of function?* Yes No Do you ever experience sudden involuntary muscle contractures or jerks in any individual parts of your limbs or face?* Yes No Do you ever experience sudden involuntary head rotation and your eyes move forcefully to one side?* Yes No Do you ever experience sudden involuntary shift in your eyes to the side or upwards?* Yes No Do you ever experience sudden vocalization of random words or notice a sudden inability to speak?* Yes No Do you ever experience any spontaneous sensations of tingling, pins and needles” numbness, coldness, burning or other random sensations in any region of your body?* Yes No Do you ever experience a ringing sensation in your ears (tinnitus), sounds, or voices spontaneously?* Yes No Do you ever experience spontaneous perception of smells such as burning rubber, foul smells, or other odors without finding the source of the odor?* Yes No Do you ever experience flashing lights, stars, or jagged lines in your visual field?* Yes No NameThis field is for validation purposes and should be left unchanged.
