Brain Region Localization form

Brain Region Localization Form

adapted from Datis Kharrazian, MD, 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.
Click to edit

MonthDayYearHourMinutesAM/PM Option
Email*
example@example.com
Full Name

First NameLast Name
Birth Date*

MonthDayYear
What state do you Reside in?*
Would You Like Dr. Rinde to contact you with comments on this form?

YesNoNot Applicable

Frontal lobe Prefrontal, Dorsolateral and Orbitofrontal (Areas 9, 10, 11, and 12)

	almost never (0)	sometimes (mild)-1	often (moderate)-2	most of the time (frequent )-3	Always (severe)-4
1. Difficulty with restraint and controlling impulses or desires
2. Emotional instability (lability)
3. Difficulty planning and organizing
4. Difficulty making decisions
5. Lack of motivation, enthusiasm, interest and drive (apathetic)
6. Difficulty getting a sound or melody out of your thoughts (Perseveration)
7. Constantly repeat events or thoughts with difficulty letting go
8. Difficulty initiating and finishing tasks
9. Episodes of depression
10. Mental fatigue
11. Decrease in attention span
12. Difficulty staying focused and concentrating for extended periods of time
13. Difficulty with creativity, imagination, and intuition
14. Difficulty in appreciating art and music
15.Difficulty with analytical thought
16. Difficulty with math, number skills and time consciousness
17. Difficulty taking ideas, actions, and words and putting them in a linear sequence

Frontal Lobe Precentral and Supplementary Motor Areas (Area 4 and 6)

	almost never (0)	sometimes (mild)-1	often (moderate)-2	most of the time (frequent )-3	Always (severe)-4
18 Initiating movements with your arm or leg has become more difficult
19.Feeling of arm or leg heaviness, especially when tired
20.Increased muscle tightness in your arm or leg
21.Reduced muscle endurance in your arm or leg
22.Noticeable difference in your muscle function or strength from one side to the other
23. Noticeable difference in your muscle tightness from one side to the other

Frontal Lobe Broca’s Motor Speech Area (Area 44 and 45)

	almost never (0)	sometimes (mild)-1	often (moderate)-2	most of the time (frequent )-3	Always (severe)-4
24.Difficulty producing words verbally, especially when fatigued
25.Find the actual act of speaking difficult at times
26.Notice word pronunciation and speaking fluency change at times

Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3,1,2 and 7)

	almost never (0)	sometimes (mild)-1	often (moderate)-2	most of the time (frequent )-3	Always (severe)-4
27, Difficulty in perception of position of limbs
28. Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall
29. Frequently bumping body or limbs into the wall or objects accidently
30.Reoccurring injury in the same body part or side of the body
31.Hypersensitivities to touch or pain perception

Parietal Inferior Lobule (Area 39 and 40)

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
32 Right/left confusion
33.Difficulty with math calculations
34.Difficulty finding words
35.Difficulty with writing
36.Difficulty recognizing symbols or shapes
37.Difficulty with simple drawings
38.Difficulty interpreting maps

Temporal Lobe Auditory Cortex (Areas 41, 42)

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
39. Reduced function in overall hearing
40.Difficulty interpreting speech with background or scatter noise
41.Difficulty comprehending language without perfect pronunciation
42.Need to look at someone’s mouth when they are speaking to understand what they are saying
43.Difficulty in localizing sound
44.Dislike of left predictable rhythmic, repeated tempo and beat music
45.Dislike of non-predictable rhythmic with multiple instruments
46.Noticeable ear preference when using your phone

Temporal Lobe Auditory Association Cortex (Area 22)

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
47. Difficulty comprehending meaning of spoken word
48.Tend toward monotone speech without fluctuations or emotions

Medial Temporal lobe and Hippocampus

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
49. Memory less efficient
50.Memory loss that impacts daily activities
51.Confusion about dates, the passage of time, or place
52.Difficulty remembering events
53.Misplacement of things and difficulty retracing steps
54.Difficulty with memory of locations (addresses)
55.Difficulty with visual memory
56.Always forgetting where you put items such as keys, wallet, phone, etc.
57.Difficulty remembering faces
58.Difficulty remembering names with faces
59.Difficulty with remembering words
60.Difficulty remembering numbers
61.Difficulty remembering to stay or be on time

Occipital Lobe (Area, 17, 18, and 19)

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
62. Difficulty in discriminating similar shades of color
63.Dullness of colors in visual
64. Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach out for objects
66.Floater or halos in visual field

Cerebellum - Spinocerebellum

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
67.Difficulty with balance, or balance that is worse on one side
68.A need to hold the handrail or watch each step carefully when going down stairs
69.Feeling unsteady and prone to falling in the dark
70.Proness to sway to one side when walking or standing

Cerebellum - Cerebrocerebellum

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
71.Recent clumsiness in hands
72.Recent clumsiness in feet or frequent tripping
73. A slight hand shake when reaching for something at the end of movement

Cerebellum - Vestibulocerebellum

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
74. Episodes of dizziness or disorientation
75.Back muscles that tire quickly when standing or walking
76.Chronic neck or back muscle tightness
77. Nausea, car sickness, or sea sickness
78.Feeling of disorientation or shifting of the environment
79.Crowded places cause anxiety

Basal Ganglia Direct Pathway

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
80.Slowness in movements
81.Stiffness in your muscles (not joints) that goes away when you move
82. Cramping of hands when writing
83.A stooped posture when walking
84.Voice has become softer
85.Facial expression changed leading people to frequently ask if you are upset or angry

Basal Ganglia InDirect Pathway

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
86.Uncontrollable muscle movements
87.Intense need to clear your throat regularly or contract a group of muscles
88.Obsessive compulsive tendencies
89.Constant nervousness and restless mind

Autonomic Reduced Parasympathetic Activity

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
90. Dry mouth or eyes
91.Difficulty swallowing supplements or large bites of food
92. Slow bowel movements and tendency for constipation
93.Chronic digestive complaints
94.Bowel or bladder incontinence resulting in staining your underwear

Autonomic Increased Sympathetic Activity

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)	Always (4)
95.Tendency for anxiety
96.Easily startled
97.Difficulty relaxing
98.Sensitive to bright or flashing lights
99.Episodes of racing heart
100.Difficulty sleeping

Feel freee to add additional comments here
Dietary Questions pertaining to digestive health
Which of the following do you have any known or suspected sensitivities to.

GlutenMilkCornSoyEggsNightshadesOther (please explain)
Feel freee to add additional comments here
Should be Empty:

Brain Region Localization Form