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1. Difficulty with restraint and controlling impulses or desires 0 1 2 3 4
2. Emotional instability (lability) 0 1 2 3 4
3. Difficulty planning and organizing 0 1 2 3 4
4. Difficulty making decisions 0 1 2 3 4
5. Lack of motivation, enthusiasm, interest and drive (apathetic) 0 1 2 3 4
6. Difficulty getting a sound or melody out of your thoughts (Perseveration) 0 1 2 3 4
7. Constantly repeat events or thoughts with difficulty letting go 0 1 2 3 4
8. Difficulty initiating and finishing tasks 0 1 2 3 4
9. Episodes of depression 0 1 2 3 4
10. Mental fatigue 0 1 2 3 4
11. Decrease in attention span 0 1 2 3 4
12. Difficulty staying focused and concentrating for extended periods of time 0 1 2 3 4
13. Difficulty with creativity, imagination, and intuition 0 1 2 3 4
14. Difficulty in appreciating art and music 0 1 2 3 4
15. Difficulty with analytical thought 0 1 2 3 4
16. Difficulty with math, number skills and time consciousness 0 1 2 3 4
17. Difficulty taking ideas, actions, and words and putting them in a linear sequence 0 1 2 3 4
18. Initiating movements with your arm or leg has become more difficult 0 1 2 3 4
19. Feeling of arm or leg heaviness, especially when tired 0 1 2 3 4
20. Increased muscle tightness in your arm or leg 0 1 2 3 4
21. Reduced muscle endurance in your arm or leg 0 1 2 3 4
22. Noticeable difference in your muscle function or strength from one side to the other 0 1 2 3 4
23. Noticeable difference in your muscle tightness from one side to the other 0 1 2 3 4
24. Difficulty producing words verbally, especially when fatigued 0 1 2 3 4
25. Find the actual act of speaking difficult at times 0 1 2 3 4
26. Notice word pronunciation and speaking fluency change at times 0 1 2 3 4
27. Difficulty in perception of position of limbs 0 1 2 3 4
28. Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall 0 1 2 3 4
29. Frequently bumping body or limbs into the wall or objects accidently 0 1 2 3 4
30. Reoccurring injury in the same body part or side of the body 0 1 2 3 4
31. Hypersensitivities to touch or pain perception 0 1 2 3 4
32. Right/left confusion 0 1 2 3 4
33. Difficulty with math calculations 0 1 2 3 4
34. Difficulty finding words 0 1 2 3 4
35. Difficulty with writing 0 1 2 3 4
36. Difficulty recognizing symbols or shapes 0 1 2 3 4
37. Difficulty with simple drawings 0 1 2 3 4
38. Difficulty interpreting maps 0 1 2 3 4
39. Reduced function in overall hearing 0 1 2 3 4
40. Difficulty interpreting speech with background or scatter noise 0 1 2 3 4
41. Difficulty comprehending language without perfect pronunciation 0 1 2 3 4
42. Need to look at someone’s mouth when they are speaking to understand what they are saying 0 1 2 3 4
43. Difficulty in localizing sound 0 1 2 3 4
44. Dislike of left predictable rhythmic, repeated tempo and beat music 0 1 2 3 4
45. Dislike of non-predictable rhythmic with multiple instruments 0 1 2 3 4
46. Noticeable ear preference when using your phone 0 1 2 3 4
47. Difficulty comprehending meaning of spoken word 0 1 2 3 4
48. Tend toward monotone speech without fluctuations or emotions 0 1 2 3 4
49. Memory less efficient 0 1 2 3 4
50. Memory loss that impacts daily activities 0 1 2 3 4
51. Confusion about dates, the passage of time, or place 0 1 2 3 4
52. Difficulty remembering events 0 1 2 3 4
53. Misplacement of things and difficulty retracing steps 0 1 2 3 4
54. Difficulty with memory of locations (addresses) 0 1 2 3 4
55. Difficulty with visual memory 0 1 2 3 4
56. Always forgetting where you put items such as keys, wallet, phone, etc. 0 1 2 3 4
57. Difficulty remembering faces 0 1 2 3 4
58. Difficulty remembering names with faces 0 1 2 3 4
59. Difficulty with remembering words 0 1 2 3 4
60. Difficulty remembering numbers 0 1 2 3 4
61. Difficulty remembering to stay or be on time 0 1 2 3 4
37. 92. visual
62. Difficulty in discriminating similar shades of color 0 1 2 3 4
63. Dullness of colors in visual field 0 1 2 3 4
64. Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach out for objects 0 1 2 3 4
66. Floater or halos in visual field 0 1 2 3 4
67. Difficulty with balance, or balance that is worse on one side 0 1 2 3 4
68. A need to hold the handrail or watch each step carefully when going down stairs 0 1 2 3 4
69. Feeling unsteady and prone to falling in the dark 0 1 2 3 4
70. Proness to sway to one side when walking or standing 0 1 2 3 4
71. Recent clumsiness in hands 0 1 2 3 4
72. Recent clumsiness in feet or frequent tripping 0 1 2 3 4
73. A slight hand shake when reaching for something at the end of movement 0 1 2 3 4
74. Episodes of dizziness or disorientation 0 1 2 3 4
75. Back muscles that tire quickly when standing or walking 0 1 2 3 4
76. Chronic neck or back muscle tightness 0 1 2 3 4
77. Nausea, car sickness, or sea sickness 0 1 2 3 4
78. Feeling of disorientation or shifting of the environment 0 1 2 3 4
79. Crowded places cause anxiety 0 1 2 3 4
80. Slowness in movements 0 1 2 3 4
81. Stiffness in your muscles (not joints) that goes away when you move 0 1 2 3 4
82. Cramping of hands when writing 0 1 2 3 4
83. A stooped posture when walking 0 1 2 3 4
84. Voice has become softer 0 1 2 3 4
85. Facial expression changed leading people to frequently ask if you are upset or angry 0 1 2 3 4
86. Uncontrollable muscle movements 0 1 2 3 4
87. Intense need to clear your throat regularly or contract a group of muscles 0 1 2 3 4
88. Obsessive compulsive tendencies 0 1 2 3 4
89. Constant nervousness and restless mind 0 1 2 3 4
90. Dry mouth or eyes 0 1 2 3 4
91. Difficulty swallowing supplements or large bites of food 0 1 2 3 4
92. Slow bowel movements and tendency for constipation 0 1 2 3 4
93. Chronic digestive complaints 0 1 2 3 4
94. Bowel or bladder incontinence resulting in staining your underwear 0 1 2 3 4
95. Tendency for anxiety 0 1 2 3 4
96. Easily startled 0 1 2 3 4
97. Difficulty relaxing 0 1 2 3 4
98. Sensitive to bright or flashing lights 0 1 2 3 4
99. Episodes of racing heart 0 1 2 3 4
100. Difficulty sleeping 0 1 2 3 4