Name(*)
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Age
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Sex
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Date
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Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Section 1

A decrease in attention span
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Mental fatigue
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Difficulty learning new things
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Difficulty staying focused and concentrating for extended periods of time
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Experiencing fatigue when reading sooner than in the past
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Experiencing fatigue when driving sooner than in the past
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Need for caffeine to stay mentally alert
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Overall brain function impairs your daily life
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Section 2

Twitching or tremor in your hands and legs when resting
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Handwriting has gotten smaller and more crowded together
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A loss of smell to foods
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Stiffness in shoulders and hips that goes away when you start to move
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Constipation
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Voice has become softer
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Facial expression that is serious or angry
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Episodes of dizziness or light-headedness upon standing
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A hunched over posture when getting up and walking
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Section 3

Memory loss that impacts daily activities
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Difficulty planning, problem solving, or working with numbers
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Difficulty completing daily tasks
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Confusion about dates, the passage of time, or place
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Difficulty understanding visual images and spatial relationships (addresses and locations)
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Difficulty finding words when speaking
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Misplacement of things and inability to retrace steps
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Poor judgement and bad decisions
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Disinterest in hobbies, social activities, or work
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Personality or mood changes
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Section 4

Reduced function in overall hearing
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Difficulty understanding language with background or scatter noise
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Ringing or buzzing in the ear
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Difficulty comprehending language without perfect pronunciation
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Difficulty recognizing familiar faces
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Changes in comprehending the meaning of sentences, written or spoken
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Difficulty with verbal memory and finding words
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Difficulty remembering events
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Difficulty recalling previously learned facts and names
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Inability to comprehend familiar words when read
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Difficulty spelling familiar words
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Monotone, unemotional speech
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Difficulty understanding the emotions of others when they speak (nonverbal cues)
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Disinterest in music and a lack of appreciation for melodies
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Difficulty with long-term memory
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Memory impairment when doing the basic activities of daily living
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Difficulty with directions and visual memory
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Noticeable differences in energy levels throughout the day
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Section 5

Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach for objects.
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Difficulty comprehending written text
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Floaters or halos in your visual field
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Dullness of colors in your visual field during different times of the day
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Difficulty discriminating similar shades of color
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Section 6

Difficulty with detailed hand coordination
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Difficulty with suppressing socially inappropriate thoughts
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Socially inappropriate behavior
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Decisions made based on desires, regardless of the consequences
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Difficulty motivating yourself to start and finish tasks
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A loss of attention and concentration
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Section 7

Hypersensitivities to touch or pain
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Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall
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Frequently bumping into the wall or objects
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Difficulty with right-left discrimination
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Handwriting has become sloppier
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Difficulty with basic math calculations
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Difficulty finding words for written or verbal communication
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Difficulty finding words for written or verbal communication
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Section 8

Difficulty swallowing supplements or large bites of food
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Bowel motility and movements slow
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Bloating after meals
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Dry eyes or dry mouth
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A racing heart
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A flutter in the chest or an abnormal heart rhythm
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Bowel or bladder incontinence resulting in staining your underwear
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Section 9

A decrease in movement speed
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Difficulty initiating movement
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Stiffness in your muscles (not joints)
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A stooped posture when walking
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Cramping of your hand when writing
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Section 10

Abnormal body movements (such as twitching legs)
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Desires to flinch, clear your throat, or perform some type of movement
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Constant nervousness and a restless mind
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Compulsive behaviors
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Increased tightness and tone in specific muscles
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Section 11

Difficulty with balance, or balance that is noticeably worse on one side
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A need to hold the handrail or watch each step carefully when going down stairs
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Episodes of dizziness
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Nausea, car sickness, or seasickness
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A quick impact after consuming alcohol
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A slight hand shake when reaching for something
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Back muscles that tire quickly when standing or walking
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Chronic neck or back muscle tightness
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