Brain Region Localization Form

Step 1 of 3 - Section: 1


The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please answer every question, do not skip any questions. Follow the 0 to 4 key, and select which best fits for all of your answers.


0 = I never have symptoms (0% of the time) 1 = I rarely have symptoms (Less than 25% of the time) 2 = I often have symptoms (Half of the time) 3 = I frequently have symptoms (75% of the time) 4 = I always have symptoms (100% of the time)
MM slash DD slash YYYY

Frontal lobe Prefrontal, Dorsolateral and Orbitofrontal (Areas 9, 10, 11, and 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 (R)
Difficulty in appreciating art and music (R)
Difficulty with analytical thought (L)
Difficulty with math, number skills and time consciousness (L)
Difficulty taking ideas, actions, and words and putting them in a linear sequence (L)

Frontal Lobe Precentral and Supplementary Motor Areas (Area 4 and 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 (Area 44 and 45)

Difficulty in perception 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 accidently
Reoccurring injury in the same body part or side of the body
Hypersensitivities to touch or pain perception