Neurological Intake Form

    For each of the following questions, please select the choice that best applies to you. Please respond to each and every question. Thank you.

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

    Difficulty with restraint and controlling impulses or desires
    Emotional instability (lability)
    Difficulty planning and organizing
    Difficulty making decisions
    Lack of motivation enthusiasm, interest and drive (apathetic)
    Difficulty getting a sound or melody out of your thoughts (perseveration)
    Constantly repeat events or thoughts with difficulty letting go
    Difficulty initiating and finishing tasks
    Episodes of depression
    Mental fatigue
    Decrease in attention span
    Difficulty staying focused and concentrating for extended periods of time
    Difficulty with creativity, imagination and intuition
    Difficulty in appreciating art and music
    Difficulty with analytical thought
    Difficulty taking ideas, actions, and words and putting them in a linear sequence

    Frontal Lobe Precentral and Supplementary Motor Area (Areas 4 & 6)
    Initiating movements with your arm or leg has become more difficult
    Feeling of arm or leg heaviness, especially when tired
    Increased muscle tightness in your arm or leg
    Reduced muscle endurance in your arm or leg
    Noticeable difference in your muscle function or strength from one side to the other
    Noticeable difference in your muscle tightness from one side to the other

    Frontal Lobe Broca's Motor Speech Area (Areas 44 & 45)
    Difficulty producing words verbally, especially when fatigued
    Find the actual act of speaking difficult at times
    Notice word pronunciation and speaking fluency change at times

    Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3, 1, 2 & 7)
    Difficulty in perceptions of position of limbs
    Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall
    Frequently bumping body or limbs into the wall or objects accidentally
    Recurring injury in the same body part or side of the body
    Hypersensitivities to touch or pain perception

    Parietal Inferior Lobule (Areas 39 & 40)
    Confusion of Right/Left
    Difficulty with math calculations
    Difficulty finding words
    Difficulty with writing
    Difficulty recognizing symbols or shapes
    Difficulty with simple drawings
    Difficulty interpreting maps

    Temporal Lobe Auditory Cortex (Areas 41 & 42)
    Reduced function in overall hearing
    Difficulty interpreting speech with background or scatter noise
    Difficulty comprehending language without perfect pronunciation
    Need to look at someone's mouth when they are speaking to understand what they are saying
    Difficulty in localizing sound
    Noticeable ear preference when using your phone

    Temporal Lobe Auditory Association Cortex (Area 22)
    Difficulty comprehending meaning of spoken word
    Tend toward monotone speech without fluctuations or emotions

    Medial Temporal Lobe and Hippocampus
    Memory less efficient
    Memory loss that impacts daily activities
    Confusion about dates, the passage of time, or place
    Difficulty remembering events
    Misplacement of things and difficulty retracing steps
    Difficulty with memory of locations (addresses)
    Difficulty with visual memory
    Forgetting where you put items such as keys, wallet, phone, etc.
    Difficulty remembering faces
    Difficulty remembering to stay or be on time

    Occipital Lobe (Area 17, 18 & 19)
    Difficulty in discriminating similar shades of color
    Dullness of colors in visual field
    Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach out for objects
    Floaters or halos in visual field

    Cerebellum - Spinocerebellum
    Difficulty with balance, or balance that is worse on one side
    A need to hold the handrail or watch each step carefully when going down stairs
    Feeling unsteady and prone to falling in the dark
    Prone to sway to one side when walking or standing

    Cerebellum - Cerebrocerebellum
    Recent clumsiness in hands
    Recent clumsiness in feet or frequent tripping
    A slight hand shake when reaching for something at the end of movement

    Cerebellum - Vestibulocerebellum
    Episodes of dizziness or disorientation
    Back muscles that tire quickly when standing or walking
    Chronic neck or back muscle tightness
    Nausea, car sickness, or sea sickness
    Feeling of disorientation or shifting of the environment
    Crowded places cause anxiety

    Basal Ganglia Direct Pathway
    Slowness in movements
    Stiffness in your muscles (not joints) that goes away when you move
    Cramping of hands when writing
    A stooped posture when walking
    Voice has become softer
    Facial expressions changed leading people to frequently ask if you are upset or angry

    Basal Ganglia Indirect Pathway
    Uncontrollable muscle movements
    Intense need to clear your throat regularly or contract a group of muscles
    Obsessive compulsive tendencies
    Constant nervousness and restless mind

    Autonomic Reduced Parasympathetic Activity
    Voice has become softer
    Dry mouth or eyes
    Difficulty swallowing supplements or large bites of food

    Autonomic Increased Sympathetic Activity
    Tendency for anxiety
    Easily startled
    Difficulty relaxing
    Sensitive to bright or flashing lights
    Episodes of racing heart
    Difficulty sleeping

    Epileptiform Activity
    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 ever experienced sudden muscle stiffness and rigidity throughout your body?
    Have you ever experienced a total loss of your muscle tone that led to loss of control of your muscles or fall?
    Have you ever been told that you stare into space while you're lip smacking, chewing or fidgeting--that you are aware of?
    Do you ever experience sudden emotional responses such as anxiety, sadness, cry, or laugh for no reason?
    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 head rotation and your eyes move forcefully to one side?
    Do you ever experience a sudden involuntary shift in your eyes to the side or upwards?
    Do you ever experience a 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 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?

    Metabolic Review
    Feeling that bowels do not empty completely
    Lower abdominal pain relieved by passing stool or gas
    More than three bowel movements daily
    Use laxatives frequently
    Excessive belching, burping or bloating
    Gas immediately following a meal
    Offensive breath
    Sense of fullness during and after meals
    Difficulty digesting fruits and vegetables; undigested foods found in stools
    Stomach pain, burning or aching 1 to 4 hours after eating
    Use antacids
    Feel hungry an hour or two after eating
    Heartburn when lying or bending forward
    Temporary relief by using antacids, food, milk or carbonated beverages
    Digestive problems subside with rest and relaxation
    Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol and caffeine
    Indigestion and fullness last 2 to 4 hours after eating
    Pain, tenderness, soreness on left side under the rib cage
    Nausea and/or vomiting
    Frequent urination
    Increased thirst and appetite
    Difficulty losing weight
    Greasy or high fat foods cause distress
    Lower bowel gas and/or bloating several hours after eating
    Bitter metallic taste in mouth, especially in the morning
    Unexplained itchy skin
    Yellow cast to eyes
    Stool color alternates from clay colored to normal brown
    Reddened skin, especially palms
    Dry or flaky skin and/or hair
    History of gallbladder attacks or stones
    Have you had your gallbladder removed?
    Crave sweets during the day
    Eating sweets does not relieve cravings for sugar
    Irritable if meals are missed
    Depend on coffee to keep going/getting started
    Get light-headed if meals are missed
    Eating relieves fatigue
    Fatigue after meals
    Crave sweets after meals
    Waist girth is equal to or larger than hip girth?
    Crave salt
    Afternoon fatigue
    Dizziness when standing up quickly
    Afternoon headaches
    Headaches with exertion and stress
    Weak nails
    Excessive perspiration or perspiration with little or no activity
    Feel cold--hands, feet, all over
    Difficult, infrequent bowel movements
    Depression/lack of motivation
    Morning headaches that wear off as the day progresses
    Outer third of eyebrow thins
    Thinning of hair on scalp, face, or genitals; excessive hair loss
    Dryness of skin and/or scalp
    Mental sluggishness
    Heart palpitations
    Inward trembling
    Night sweats
    Diminished sex drive
    Increased sex drive
    Urination difficulty or dribbling
    Pain inside legs or heels
    Feeling of incomplete emptying
    Leg twitching at night

    Metabolic Review--Male Patients
    Decreased number of spontaneous erections
    Decreased fullness of erections

    Metabolic Review--Female Patients
    Decreased physical stamina
    Painful intercourse
    Decreased physical stamina
    Extended menstrual cycle (greater than every 32 days)
    Shortened menstrual cycle (less than every 24 days)
    Pain and cramping during menses
    Pelvic pain during menses
    Irritable and depressed during menses
    Facial hair growth
    How many years have you been menopausal
    Since menopause, do you have any uterine bleeding
    Hot flashes
    Painful intercourse
    Shrinking breasts
    Vaginal pain, dryness or itching

    Thank you for taking the time to review your health history.
    The Revive Team