Brain Tissue Donation Questionnaire
What symptoms has the patient experienced since the initial onset( check all that apply):
10
Movement symptoms: q Tremors q Imbalance / frequent falls q Difficulty with walking q Difficulty with general coordination q Difficulty moving / using hands q Stiffness / rigidity of muscles q Painful muscle contractions
(“ dystonia”)
Other: ________________________________ _______________________________________ _______________________________________ ______________________________________
Vision changes: q Double vision q Blurry vision q Dry eyes q Difficulty moving eyes q Difficulty opening and / or closing eyelids
Other: ________________________________ _______________________________________ _______________________________________ ______________________________________
Cognitive changes: q Short-term memory loss q Long-term memory loss q Loss of orientation( e. g., not knowing the year, familiar locations, familiar people) q Difficulty with word finding q Poor judgment q Disinhibited behavior q Impulsivity q Delusions( e. g., paranoia) q Hallucinations q Uncontrolled laughing or crying q Personality changes
Other: _____________________________ ____________________________________ ____________________________________ ___________________________________
Sleep changes: q Development of sleep apnea q Acting out dreams q Restless leg syndrome q Difficulty falling or staying asleep at night q Daytime fatigue / sleepiness
Other: _____________________________ ____________________________________ ____________________________________ ___________________________________
Autonomic symptoms: q Dizziness q Difficulty with blood pressure regulation / fainting q Excessive sweating q Changes to breathing( e. g., shortness of breath, labored breathing, sudden large breaths) q Changes to bladder or bowel function q Sexual dysfunction q Changes to circulation
( e. g., discoloration in hands or feet)
Other: ________________________________ _______________________________________ _______________________________________ ______________________________________
Other symptoms: q Changes to speech / voice q Difficulty with swallowing q Weight loss q Anxiety q Depression q Apathy Other: _____________________________ ____________________________________ ____________________________________ ___________________________________
Does the patient have a known history of: Alcoholism: q Yes q No Drug use: q Yes q No High blood pressure: q Yes q No Other known medical conditions or primary symptoms: ___________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________