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Stroke Fitness Assessment (INTL)

Welcome! 
please fill in the form, using the following guidelines:

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