Brain Region Localization Form

Name

First NameLast Name

Key:

0= 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 symptons (100% of the time)

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

	0	1	2	3	4
1. Difficult 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 (preservation)
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 and extended periods of time
13. Difficulty with creativity imagination, and intuition
14. Difficulty in appreciating art and music
15. Difficulty with analytic thought
16. Difficulty with math, number, skills and time consciousness
17. Difficulty taking ideas, actions, and words and putting them in a linear sentence

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

	0	1	2	3	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)

	0	1	2	3	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 (Area 3,1,2, and 7)

	0	1	2	3	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 accidentally
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)

	0	1	2	3	4
32. Right/ Left confusion L
33. Difficulty with math calculations L
34. Difficulty with finding words L
35. Difficulty with writing L
36. Difficulty recognizing symbols and shapes R
37. Difficulty with simple drawings R
38. Difficulty interpreting maps R

Temporal Lobe Auditory Cortex (Areas 41, 42)

	0	1	2	3	4
39. Reduced function in overall hearing
40. Difficulty interpreting speech with background 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 L
45. Dislike of non-predictable rhythmic with multiple instruments R

Temporal Lobe Auditory Cortex (Areas 41, 42)

	Right	Left	No Preference
46. Noticeable ear preference when using your phone

Temporal Lobe Auditory Association Cortex (Area 22)

	0	1	2	3	4
47. Difficulty comprehending meaning of spoken words L
48. Tend toward monotone speech without fluctuations or emotions R

Medical Temporal Lobe and Hippocampus

	0	1	2	3	4
49. Memory loss 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) R
55. Difficulty with visual memory R
56. Always forgetting where you put items such as keys, wallet, phone, etc R
57. Difficulty remembering faces R
58. Difficulty remembering names with faces L
59. Difficulty with remembering words L
60. Difficulty with remembering numbers L
61. Difficulty remembering to stay or be on time (reduced left) L

Occipital Lobe (Area 17m 18, and 19)

	0	1	2	3	4
62. Difficulty in discriminating similar shades of colors
63. Dullness of colors in visual field
64. Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach out for objects
65. Floater or halos in visual field

Cerebellum - Spinocerebellum

	0	1	2l	3	4
66. Difficulty with balance, or balance that is worse on one side
67. A need to hold the handrail or watch each step carefully when going down stairs
68. Feeling unsteady and prone to falling in the dark
69. Proness to sway to one side when walking or standing

Cerebellum - Cerebrocerebellum

	0	1	2	3	4
70. Recent clumsiness in hands
71.Recent clumsiness in feet or frequent tripping
72. A slight hand shake when reaching for something at the end of movement

Cerebellum - Vestibulocerebellum

	0	1	2	3	4
73. Episodes of dizziness or disorientation
74. Back muscles that tire quickly when standing or walking
75. Chronic neck or back muscle tightness
76. Nausea, car sickness, or sea sickness
77. Feeling of disorientation or shifting of the environment
78. Crowded places cause anxiety

Basal Ganglia Direct Pathway

	0	1	2	3	4
79. Slowness in movement
80. Stiffness in your muscles (not joints) that goes away when you move
81. Cramping of hands when writing
82. A stooped posture when walking
83. Voice has become softer
84. Facial expression changed leading people to frequently ask if you are upset or angry

Basal Ganglia Indirect Pathway

	0	1	2	3	4
85. Uncontrollable muscle movements
86. Intense need to clear your throat regularly or contract a group of muscles
87. Obsessive compulsive tendencies
88. Constant nervousness and restless mind

Autonomic Reduced Parasympathetic Activity

	0	1	2	3	4
89. Dry mouth or eyes
90. Difficulty swallowing supplements or large bites of food
91. Slow bowel movements and tendency for constipation
92. Chronic digestive complaints
93. Bowel or bladder incontinence resulting in staining your underwear

Autonomic Increased Sympathetic Activity

	0	1	2	3	4
94. Tendency for anxiety
95. Easily startled
96. Difficulty relaxing
97. Sensitive to bright or flashing lights
98. Episodes of heart racing
99. Difficulty sleeping

Instructions: The purpose of this questionnaire is to identify difficulties you may be experiencing. Please select yes or no.

	Yes	No
Have you ever been diagnosed with a seizure disorder?
Have you ever been diagnosed with epilepsy?
Have you ever been told that you seemed frozen, absent, or tuned out at times without any recollection of the event?
Have you every experienced sudden muscle stiffness and rigidity throughout your body?
Have you ever experienced sudden muscle jerks throughout your body?
Have you ever experienced a total loss of your muscle tone that lead to loss of control of your muscles or a fall?
Have you ever been told that you state into space while you're lip smacking, chewing, or fidgeting that you are not aware of?
Do you ever expereince sudden emotional responses such as anxiety, sadess, cry or laugh for no real reason?
Do you ever experience sudden racing heart rate, sudden loss of bladder function, intestinal spasm, respiration, sweating, or any other sudden changes in function?
Do you ever experience sudden involuntary muscle contractures or jerks in any individual parts of your limbs or face?
Do you ever experience sudden involuntary shift in your eyes to the side or upwards?
Do you ever experience sudden vocalization of random words or notice a sudden inability to speak?
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?
Do you ever experience a ringing sensation in your ears (tinnitus), sounds, or voices spontaneously?
Do you ever experience spontaneous perception of smells such as burning rubber, foul smells, or other odors without finding the source of the odor?
Do you ever experience flashing lights, stars, or jagged lines in your visual field?

Gait, please mark the most applicable to you

	No	Yes - Mild	Yes - Moderate	Yes - Severe
Do you fall frequently?
Do you have a hard time standing on your toes or heels?
Do you fall to one side?
Do you walk with our legs wide or far apart?
Do you waddle when you walk?
Do you have a hard time going up or down stairs?
Is one or both arms tight or spastic?
Is one or both of your legs spastic?
Do your feet slap when you walk?
Do you have to high step when you walk?
Do you shuffle when you walk?
Is it hard to start walking?
Is it hard to turn if you stop walking?

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