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Stroke and Young Adults (SAYA) Program - Late Complications of Stroke Screening Tool

Have you had any of these symptoms since your last visit? Place a checkmark in the “Yes” or “No” box. Click Submit at the end of the questionnaire to send this information to the Stroke Coordinator who will direct this information to your Neurologist.

General Information
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Language and Speech
Are you having trouble finding words or putting words together in a sentence?
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Are you having trouble understanding others?
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Are you having trouble pronouncing words clearly?
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Movement and Walking
Are you having trouble moving one side of your face or body?
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Are you having difficulty swallowing food or fluid?
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Are you having difficulty walking or maintaining your balance when standing?
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Have you had any falls?
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Seizures
Are you having episodes where you pause or stop what you are doing for a long period of time (15+ seconds)? (For example, do you suddenly stop speaking in conversation?)
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Do you have episodes where you lose a period of time? (For example, several minutes)
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Do you get any twitching of the muscles on one side of your face or body?
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Do you get any brief, repetitive, odd sensations such as abnormal smells, tastes, distortions of vision, the feeling of déjà vu, or a rising sensation like a wave coming up the chest?
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Have you have had any episodes where you fall to the ground, stiffen, and shake?
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Headaches and Pain
Are you getting headaches or neck pain?
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Are you having tightness in the muscle or joints of your limbs on one side?
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Are you getting muscle spasms in your neck, arm, hand, back, hip, leg, or foot?
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Are you having burning, tingling, sharp, or electrical sensations on one side?
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Lightheadedness and Dizziness
Do you get lightheaded when you stand up?
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Fatigue and Sleep
Are you feeling very tired during the daytime since your stroke?
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Are you sleeping many more hours than before your stroke?
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Are you having trouble falling asleep or staying asleep?
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Do you snore loudly during your sleep or awaken during the night gasping for air?
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Cognitive
Are you having trouble concentrating on tasks?
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Are you having difficulty remembering things?
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Mood
Do you feel sad or depressed?
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Have you been irritable or easily upset by others?
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Have you been having nightmares or flashbacks about your stroke?
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Have you been feeling anxious?
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Employment
If you were working before your stroke, have you returned to work?
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Are you having difficulty returning to work?
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Social
Have you spent time with friends or other people since your stroke?
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Do you feel isolated or alone?
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