Form – Brain Function Assessment Form (BFAF)

MM slash DD slash YYYY

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

SECTION 2

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

SECTION 3

Memory loss that impacts daily activities
Difficulty planning, problem solving, or working with numbers
Difficulty completing daily tasks
Confusion about dates, the passage of time, or place 0
Difficulty understanding visual images and spatial relationships (addresses and locations)
Difficulty finding words when speaking
Misplacement of things and inability to retrace steps
Poor judgment and bad decisions
Disinterest in hobbies, social activities, or work
Personality or mood changes

SECTION 4

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

SECTION 5

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

SECTION 6

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

SECTION 7

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

SECTION 8

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

SECTION 9

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

SECTION 10

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

SECTION 11

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

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