New Client – Adult – NeuroLightsOn

New Client - Adult

Step 1 of 10 - Section: 1

10%

Name

First Middle Last

Birthdate

MM slash DD slash YYYY

Birth Order

Age

Gender

Male

Female

Email Address:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Telephone

Cell or Other Number

Referred By

Chief Concern(s)

NEUROLOGICAL ASSESSMENT FORM

Name

Sex

Date

MM slash DD slash YYYY

Are you left or right handed?

Left

Right

Have you ever had a head injury?

Yes

Have you ever lost consciousness?

Yes

Do you currently experience of have a past history of dizziness?

Yes

Do you have any ringing in the ears?

Yes

Do you experience nausea?

Yes

Do you find that your balance is getting worse?

Yes

Do you have difficulties going down stairs?

Yes

Do you have a hard time with math problems or computing numbers?

Yes

Do you find yourself searching for words frequently when you speak?

Yes

Have you noticed your ability to concentrate is getting worse?

Yes

Do you fatigue after reading?

Yes

Do you get lost often or have a hard time with directions?

Yes

Does loud or scattered noise bother you?

Yes

Do quick flashes of light on TV or movies bother you?

Yes

Do you feel like you need to wear sunglasses outside?

Yes

Has you handwriting changed in recent years?

Yes

Do you have a hard time swallowing?

Yes

Do you gag easily?

Yes

Do you experience blurriness in your vision?

Yes

Do you ever have double-vision?

Yes

Do you have any difficulty with smell?

Yes

Do you smell foul things that are not present?

Yes

Do you have any difficulty with taste?

Yes

Do you taste things differently than what you are eating?

Yes

Have you noticed clumsiness in hand coordination?

Yes

Do you have difficulty with short-term memory?

Yes

Have you been told or noticed any memory loss of past events?

Yes

Have you noticed uneven sweating or temperature on one side of our body?

Yes

Do you have any tightness, feeling of weakness or instability in your back or neck?

Yes

Do you have any tightness, or feelings of weakness in your hands or legs?

Yes

Do you ever have any numbness or tingling in your hands, legs or face?

Yes

Have you noticed any twitches or cramping in your legs or hands?

Yes

Do you have any difficulty with falling or staying asleep?

Yes

Do you get motion sickness easily (car sick or sea sick)?

Yes

Do you ever experience flashes of light in your visual field?

Yes

Do you ever see floating objects in your visual field?

Yes

Do you ever experience dry eyes or mouth?

Yes

Do you ever experience increase tearing or salivation?

Yes

Do you feel pressure in your ear?

Yes

Do you suffer from frequent bloating or gas?

Yes

Do you feel that you do not digest your food well?

Yes

Do you ever have slurred speech?

Yes

Do you ever have dropping of your eyelids?

Yes

Do you ever notice fatigue of your facial muscles?

Yes

Do you ever have jaw tightness or diagnosed with TMJ dysfunction?

Yes

Do you ever notice increased heart rate or pulse during the day?

Yes

Have you ever experienced or been diagnosed of arrhythmia (fluctuating heart rate)?

Yes

Have you ever been diagnosed or experienced tachycardia (fast heart rate)?

Yes

Do you experience De Ja’vu?

Yes

Does driving cause you fatigue, headaches or any other symptoms?

Yes

Does working on a computer cause you fatigue, headaches or other symptoms?

Yes

Do you ever have increased/decreased urination (normal is 6-8 a day) or wet the bed?

Yes

Do you have increased/decreased bowel (normal is 3 a day) movements?

Yes

Have you lost your interest in hobbies and functions that you used to enjoy?

Yes

Do you have a hard time motivating yourself to engage in activities?

Yes

Do you ever have fluttering of the eye or noticed you are blinking frequently?

Yes

Do you have difficulty distinguishing right and left?

Yes

Did you find this questionnaire difficult?

Yes

Please Comment or Elaborate On Any Questions Below

ADULT HEMISPHERIC CHECKLIST

Check off all items that you feel describe you, then add the total number of check marks in each section and enter the score at the bottom of each section.

Motor Characteristics of a Right Brain Deficit

You have poor coordination. You are clumsy and an odd posture and gait.

You have difficulty coordinating both sides of your body, such as in running, walking, or swimming.

You have poor muscle tone. Your muscles are flabby or floppy instead of taut.

You are very flexible, or even double jointed.

You have, and may recently have acquired, facial tics or make repetitive and involuntary vocal sounds, such as clearing the throat.

You have repetitive motor mannerisms, such as twisting or playing with your hair or pulling on your sleeves.

You have a tendency to walk on your toes.

You do not have good balance or notice it has recently gotten worse.

You have chronic tendinitis, patella tendinitis, carpal tunnel syndrome, or have or have had trouble with your rotator cuff or tennis elbow on the right side of the body.

You get a tremor or eye twitch on the right side of your body.

You cannot cross your eyes.

You have poor depth perception. For example, you have trouble judging distances or driving.

Total (A)

Motor Characteristics of a Left Brain Deficit

You have difficulty performing fine motor skills, such as buttoning a shirt and doing small detail work with hands.

You have poor handwriting or handwriting that is hard to read.

Have have difficulty planning a sequence of coordinated movements, such as dance steps or certain sports activities

You have a twitch in your right eye, but not your left.

You frequently have problems with writer’s cramp.

You stumble over words in your speech when you’re tired.

You are not musically inclined. For example, you have found it difficult to play a musical instrument.

You have chronic tendinitis, patella tendinitis, and carpal tunnel or have had rotator cuff problems or tennis elbow on left side of body.

You get tremors on the right side of the body.

You find it difficult to imitate an action without actually doing it. For example, you can’t mimic how to strike a match without using a pack of matches.

You’re ambidextrous. You don’t really favor your left hand or right hand.

Total (B)

Sensory Characteristics of a Right Brain Deficit

You have poor spatial orientation. For example, you frequently bump into things.

You are hypersensitive to sound. For example, you hate loud noises, such as fireworks, and you are especially bothered by high-pitched sounds, such as children screaming or scratching on a chalkboard.

You generally feel disconnected from body.

You compulsively touch things. For example, you’ll touch fabric when passing through an aisle in a store even though you’re not interested in buying, or you rub your hands over furniture for no particular reason when you’re in someone’s home.

You don’t like the feeling of clothing on your arms or legs. For example, you’ll pull off clothes at every chance you get.

You don’t like being touched or when people get in your personal space.

You have a poor sense of smell. For example, you don’t feel a hit when you get in an area of a wood fire burning, popcorn popping, or cookies being baked in the oven.

You have an inability to recognize or differentiate between sounds or musical notes.You may have been told you have a “tin ear” or you sing off key.

You have experienced hearing voices when no one is there or hear a ringing in your right ear.

You smell unusual scents others don’t smell or when none exists.

You get a metallic or unpleasant taste in your mouth for no discernable reason, such as a result of taking certain medications.

You are obsessed with religion or understanding the meaning of life, beyond what many would consider normal. You are always quoting scripture in almost every conversation or Facebook post.

You have unexplained lapses in time. You don’t lose consciousness, but you can’t remember certain periods of time.

Your right eye is chronically irritated, dry or red.

Hearing in your left ear is more difficult that in your right.

You seem to lose your perception of time, or you always had a poor sense of timing, meaning you over or under estimate how much time something will take.

Total (A)

Sensory Characteristics of a Left Brain Deficit

You have to think twice when distinguishing left from right.

You or others feel you do not hear well, even though hearing tests have come out normal.

You easily get motion sickness.

You are very sensitive to movement. For example, you can’t ride in a car and read at same time.

The smallest things can make you nauseated, such as the sight of blood or certain unpleasant smells.

You feel you don’t hear as well with your right ear as you do with your left.

Your left eye is chronically irritated, dry, or red.

Total (B)

Emotional Symptoms of Right Brain Deficit

You are, or appear to others to be, overly happy and affectionate. For example you love to hug and kiss others, such as your kids, friends, and pets.

Your behavior could be described as manic. You can burst into tears or laughter almost spontaneously.

You have sudden outbursts of anger and fear.

You occasionally experience panic and/or anxiety attacks.

You sometimes have dark or violent thoughts.

You hold on to past "hurts." You just can’t let go.

Your face normally lacks expression and you don’t exhibit much body language when interacting with others.

You’re too uptight. You just cannot seem to loosen up.

You are not very empathetic or do not appear to be to others.

You don’t show emotion in situations the same as others do.

You like taking risks and are known as a risk taker.

Normally, you speak in a monotone and have no expression in your voice.

You don’t like being in social situations. Others would call you anti-social.

You don’t generally ever feel “afraid“ or seem to experience fear.

Total (A)

Emotional Characteristics of Left Brain Delay

You get frightened very easily.

You frequently and easily get depressed or feel down in the dumps.

You worry a lot and are considered a worry wart by those who know you best.

You have had or think you have had post traumatic stress disorder.

You have a lot of fears and/or phobias.

You frequently get moody and irritaable.

You contemplate suicide.

You lack motivation.

You don’t get a lot of pleasure out of life, food or anything in particular.

Others would say it is hard to make you happy.

You get insulted easily.

You frequently feel overwhelmed by the tasks at hand and what’s going on in the world around you.

You can feel another’s pain and despair more than the average person.

You’re typically pessimistic. Others would call you extremely negative.

You are excessively cautious and don’t take risks.

You’re uncomfortable in social situations. You want to be sociable but you are not always sure how to act.

Your feelings are hurt easily and it can make you cry at the drop of a hat.

You sometimes have feelings of hopelessness, or feel “What’s the point?"

You are very sensitive to what others think about you.

You are overly self-conscious. Others might call you paranoid.

You often think that others are making fun of you behind your back.

You have bad memories that you just can’t let go of, especially emotional hurt or humiliation.

Total (B)

Behavioral Characteristics of a Right-Brain Deficit

You have a hard time following the rules of good communication. You say inappropriate things, talk at the wrong time, and you are not particularly expressive when talking.

You have, or others tell you, that you have a hard time staying focused on the task at hand or paying attention to what is being said or done around you for more than a few minutes.

You sometimes think you have or others accuse you of having adult ADHD. Or you have been diagnosed with it.

You obsess over practically everything. You often think or others have told you that you act like you have obsessive-compulsive disorder or you have been diagnosed with it.

You have manic-depressive highs and lows to the degree that you or others feel you might have bipolar disorder or you have been diagnosed with the disorder.

You frequently have feelings of déjà vu. You feel like you have been somewhere or experienced an event before.

You often miss the point of a story.

You get stuck in set behavior and can’t let it go. For example, you can’t transition easily to a new thought, action, or idea.

You never feel a sense of guilt or remorse.

You lack social tact and feel socially isolated.

You manage your time poorly. You are always late for appointments and meetings.

You are a neat freak and can’t stand when something is out of order.

You can’t sit still. You are impulsive, compulsive, and hyperactive.

You have a hard time getting to sleep because your mind is always racing.

You hate throwing things out and may even be accused of being a hoarder.

You’re generally uncooperative.

You have extreme eating habits, possibly to the point of an eating disorder, especially bulimia.

You often appear to others as bored, aloof, and abrupt.

You are considered strange by others or you were considered strange as a kid.

You don’t have a lot of friends. New friends you make seem to drift away.

You don’t particularly enjoy the company of others.

You act silly or giddy at inappropriate times in the presence others.

You talk incessantly and are known to others as "a talker."

You tend to ask or have been told you ask repetitive questions and talk in circles, but never really get to the point.

You could care less about fashion and social trends.

You’ve been wearing the same hair style for years.

You have been described as a “control freak.”

Total (A)

Behavioral Characteristics of a Left-Brain Deficit

You tend to be oblivious to rules and regulations. For example, you seem to “attract” parking and speeding tickets.

You have a tendency to exaggerate and/or lie.

You can feel terrible shame or crippling guilt even when you have not done anything terribly wrong.

You frequently have a foreboding feeling or sick feeling in stomach for no discernible reason.

You tend to procrastinate.

You are very shy, especially around strangers.

You have a tendency to stutter or stammer.

You have poor self esteem. You feel like a loser and you feel others think of you that way.

You have, or others say you have, an inferiority complex. You don’t feel you’re as smart as others.

You hate busywork, such as doing paperwork or paying the bills.

You are not good at following routines and establishing habits.

You get perplexed, frustrated, or annoyed when you have to follow multiple-step directions.

You tend to jump to conclusions or have been told you do too quickly.

You make mistakes because you don’t read or follow directions.

You are extremely messy.

You follow fads and trends and are beholden to the latest fashions.

You were bored in school and/or hated school work.

You just hate being alone.

You are a daydreamer and are constantly drifting off in thought.

You have a hard time doing just one thing at a time.

You constantly stop one activity or thought and start another before anything is finished.

You have an addictive personality. For example, you have been addicted to drugs, alcohol, cigarettes, gambling, sex etc.

Total (B)

Cognitive Characteristics of a Right-Brain Deficit

You have difficulty recalling the date, time, or place of important events in your life. For example, you don’t just forget birthdays and anniversaries, you sometimes have to pause to remember your age or day and year you were married.

You have trouble staying on topic during a conversation or at a meeting.

You have trouble repeating a story as told or explaining directions.

You have a tendency to fly off the handle to common annoyances, such as an overflowing sink or an overheated car engine.

You have difficulty interpreting abstract language. For example, you may not get a joke or understand a metaphor.

You cannot mentally rotate objects in space. For example, you have a hard time imagining how furniture would look in a different position of room.

You can’t seem to recognize faces of people you know who you haven’t seen in years.

You do not remember much or almost anything about your childhood.

You have a poor sense of direction.

You have difficulty using and understanding inuendo and connotation. For example, you can’t take a hint.

You don’t “get it” when someone uses irony and sarcasm.

You don’t get the moral in a story or the point an author is trying to make.

You get so stuck in the details that you have difficulty making decisions.

You have a hard time making decisions because you tend to overanalyze everything.

You have an obsessive interested in unusual topics, such as trains, rocks, stamps, comic books and the like.

You are frequently and are growing increasingly impatient.

You speak aloud what’s on your mind.

You get very close to people when speaking to them. Others would call you a space invader.

You are extremely direct to the point of being considered rude.

Total (A)

Cognitive Characteristics of a Left-Brain Deficit

You have a problem remembering details such as street names or important dates.

Colors look dull to you lately.

You have trouble remembering names and phone numbers.

You cannot learn by reading.

You have difficulty executing a plan, such as following a recipe or building a model.

You have poor analytical skills. For example, you can’t think logically in a stressful situation or analyze your odds of winning or losing in a game.

You have no sense of time. You are always late.

You have trouble prioritizing. For example, you have difficulty knowing what to do first or what is most important.

It is unlikely you would take the time to read the instruction manual before trying somethig new.

You have to tendency to miss small words when reading or omit them when writing.

You have difficulty learning new material and your reading is too slow and laborious.

Names and words get caught on the tip of your tongue.

You need to hear or see concepts many times in order to learn them.

You believe you are or were dyslexic.

When you were in school, you test scores and grades tended to be worse instead of better.

You took special education classes in grade school or high school.

You say you are poor at math.

You’re a bad speller.

You are not particular good at grammatically correct writting.

You studied a foreign language but can’t recall it or can barely recall it.

You have difficulty or can’t describe the nature of your relationships in emotional terms, such as what your relationship was with you mother when you were growing up.

You can’t remember details of your childhood, such as the address where you lived, your phone numbers, or your teachers' name.

Total (B)

Common Immune Characteristics of a Right-Brain Deficit

You have allergies.

You have a sensitivity to a food substance, such as casein or gluten.

You have or have had an autoimmune disorder such as asthma, eczema, asthma, lupus, psoriasis or rheumatoid arthritis.

You have more than one autoimmune disorder.

You have little white bumps on your skin, especially on the back of your arms.

You crave certain foods, especially dairy and wheat products.

You have been diagnosed with low thyroid function.

You feel like you’re a little drunk or feel off balance after eating certain foods.

Total (A)

Common Immune Characteristics of a Left-Brain Deficit

You have problem with chronic ear, throat, or respiratory infections.

You are prone to benign tumors and/or cysts or you have had a cancerous tumor.

You’ve taken or frequently take a lot of antibiotics or anti viral medicines.

You catch a lot of colds, more than 2 a year.

It takes you a long time to feel 100 percent after an illness.

You feel you have to get a flu shot every year or you will get the flu. You sometimes get it, even with a flu shot.

You have problem with chronic yeast or fungal infections and/or have been diagnosed with candidiasis or thrush.

You have or have had stomach ulcers.

You’ve had pneumonia within the past 7 years.

You have recurrent viral outbreaks, such as herpes or shingles.

You have had or still have Lyme disease.

You’ve had your tonsils and adenoids removed because of chronic infections.

Total (B)

Common Metabolic Characteristics of Right Brain Delay

You have frequent bowel troubles with constipation and/or diarrhea.

You have a rapid heart rate or a sudden increase in heart rate (tachycardia, above 90 beats per minute)

Your blood pressure is 10 points or more higher when taken on your right arm than your left arm.

You perspire more on the right side of your body than your left.

Total (A)

Common Metabolic Characteristics of a Left Brain Deficit

Your blood pressure is 10 points or more higher when taken on your left arm than your right arm.

You sweat more on the left side of your body.

You have or have had an irregular heartbeat, such as arrhythmia or a heart murmur.

Your left hand looses circulation & takes longer to warm up when exposed to the cold.

Total (B)

How to Score - (Neurolightson will score this for you)

Tally the number of checkmarks you made in the right-brain list of deficit symptoms (A) and leftbrain deficit symptoms (B). The highest number identifies the side of hemispheric weakness. The side with the greater number is the side of hemispheric weakness. The greater the number and the more they are different, the more severe the imbalance between the two sides.

Total number of checkmarks for right brain deficit (A)

Total number of checkmarks on left brain deficit (B)

Hemispheric weakness right or left

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New Client - Adult

NEUROLOGICAL ASSESSMENT FORM

ADULT HEMISPHERIC CHECKLIST

How to Score - (Neurolightson will score this for you)

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