Form – Brain Function Assessment Form (BFAF) Name(Required)Age:SexDate 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 1A decrease in attention span 0 1 2 3 Mental fatigue 0 1 2 3 Difficulty learning new things 0 1 2 3 Difficulty staying focused and concentrating for extended periods of time 0 1 2 3 Experiencing fatigue when reading sooner than in the past 0 1 2 3 Experiencing fatigue when driving sooner than in the past 0 1 2 3 Need for caffeine to stay mentally alert 0 1 2 3 Overall brain function impairs your daily life 0 1 2 3 SECTION 2Twitching or tremor in your hands and legs when resting 0 1 2 3 Handwriting has gotten smaller and more crowded together 0 1 2 3 A loss of smell to foods 0 1 2 3 Difficulty sleeping or fitful sleep 0 1 2 3 Stiffness in shoulders and hips that goes away when you start to move 0 1 2 3 Constipation 0 1 2 3 Voice has become softer 0 1 2 3 Facial expression that is serious or angry 0 1 2 3 Episodes of dizziness or light-headedness upon standing 0 1 2 3 A hunched over posture when getting up and walking 0 1 2 3 SECTION 3Memory loss that impacts daily activities 0 1 2 3 Difficulty planning, problem solving, or working with numbers 0 1 2 3 Difficulty completing daily tasks 0 1 2 3 Confusion about dates, the passage of time, or place 0 0 1 2 3 Difficulty understanding visual images and spatial relationships (addresses and locations) 0 1 2 3 Difficulty finding words when speaking 0 1 2 3 Misplacement of things and inability to retrace steps 0 1 2 3 Poor judgment and bad decisions 0 1 2 3 Disinterest in hobbies, social activities, or work 0 1 2 3 Personality or mood changes 0 1 2 3 SECTION 4Reduced function in overall hearing 0 1 2 3 Difficulty understanding language with background or scatter noise 0 1 2 3 Ringing or buzzing in the ear 0 1 2 3 Difficulty comprehending language without perfect pronunciation 0 1 2 3 Difficulty recognizing familiar faces 0 1 2 3 Changes in comprehending the meaning of sentences, written or spoken 0 1 2 3 Difficulty with verbal memory and finding words 0 1 2 3 Difficulty remembering events 0 1 2 3 Difficulty recalling previously learned facts and names 0 1 2 3 Inability to comprehend familiar words when read 0 1 2 3 Difficulty spelling familiar words 0 1 2 3 Monotone, unemotional speech 0 1 2 3 Difficulty understanding the emotions of others when they speak (nonverbal cues) 0 1 2 3 Disinterest in music and a lack of appreciation for melodies 0 1 2 3 Difficulty with long-term memory 0 1 2 3 Memory impairment when doing the basic activities of daily living 0 1 2 3 Difficulty with directions and visual memory 0 1 2 3 Noticeable differences in energy levels throughout the day 0 1 2 3 SECTION 5Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach for objects 0 1 2 3 Difficulty comprehending written text 0 1 2 3 Floaters or halos in your visual field 0 1 2 3 Dullness of colors in your visual field during different times of the day 0 1 2 3 Difficulty discriminating similar shades of color 0 1 2 3 SECTION 6Difficulty with detailed hand coordination 0 1 2 3 Difficulty with making decisions 0 1 2 3 Difficulty with suppressing socially inappropriate thoughts 0 1 2 3 Socially inappropriate behavior 0 1 2 3 Decisions made based on desires, regardless of the consequences 0 1 2 3 Difficulty planning and organizing daily events 0 1 2 3 Difficulty motivating yourself to start and finish tasks 0 1 2 3 A loss of attention and concentration 0 1 2 3 SECTION 7Hypersensitivities to touch or pain 0 1 2 3 Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall 0 1 2 3 Frequently bumping into the wall or objects 0 1 2 3 Difficulty with right-left discrimination 0 1 2 3 Handwriting has become sloppier 0 1 2 3 Difficulty with basic math calculations 0 1 2 3 Difficulty finding words for written or verbal communication 0 1 2 3 Difficulty recognizing symbols, words, or letters 0 1 2 3 SECTION 8Difficulty swallowing supplements or large bites of food 0 1 2 3 Bowel motility and movements slow 0 1 2 3 Bloating after meals 0 1 2 3 Dry eyes or dry mouth 0 1 2 3 A racing heart 0 1 2 3 A flutter in the chest or an abnormal heart rhythm 0 1 2 3 Bowel or bladder incontinence, resulting in staining your underwear 0 1 2 3 SECTION 9A decrease in movement speed 0 1 2 3 Stiffness in your muscles (not joints) 0 1 2 3 A stooped posture when walking 0 1 2 3 Cramping of your hand when writing 0 1 2 3 SECTION 10Abnormal body movements (such as twitching legs) 0 1 2 3 Desires to flinch, clear your throat, or perform some type of movement 0 1 2 3 Constant nervousness and a restless mind 0 1 2 3 Compulsive behaviors 0 1 2 3 Increased tightness and tone in specific muscles 0 1 2 3 SECTION 11Difficulty with balance, or balance that is noticeably worse on one side 0 1 2 3 A need to hold the handrail or watch each step carefully when going down stairs 0 1 2 3 Episodes of dizziness 0 1 2 3 Nausea, car sickness, or seasickness 0 1 2 3 A quick impact after consuming alcohol 0 1 2 3 A slight hand shake when reaching for something 0 1 2 3 Back muscles that tire quickly when standing or walking 0 1 2 3 Chronic neck or back muscle tightness 0 1 2 3 CAPTCHAEmailThis field is for validation purposes and should be left unchanged. 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