Adult Neuropsychological Evaluation

Patient Name

Would you like to authorize anyone to discuss your medical information on your behalf?

Yes

If so, please provide the full name of the authorized person.

How are they related to you?

Please Initial and Confirm Your DOB to Proceed

If another person assisted in completing this form, please provide information about them:

Name

Relationship to Patient

Address

Age

Date of Birth

Gender Identity

Preferred Pronouns

Phone Number

Email Address

Current Occupation/Last Occupation (Please state if retired)

If not working/retired, enter most recent job

Education

Handedness

Right Left Both

First Language

Primary Language

Which doctor referred you for this assessment?

If you were not referred by a doctor, put "self".

To the best of your knowledge, why were you referred for this assessment?

Which doctor(s) would you like us to fax your evaluation to?

Please provide name and fax number.

Briefly describe what problems or symptoms led you to seek help from your current treatment providers.

Approximately when did these problems or symptoms begin?

Have your symptoms:

Gotten worse?

Gotten better?

Stayed the same?

Have you received any brain MRI scans, head CT scans, or EEG studies?

Yes

If yes, please list them below:

Type of Exam, Date, and Results

Have you had any prior neuropsychological or psychological evaluation?

Yes

If yes, please list them below:

Type of Exam, Date, and Results

Please check each symptom you are experiencing below:

Cognitive Symptoms

Attention/Concentration Difficulties

Do you...

have difficulty paying attention?

have problems focusing/concentrating?

often lose your train of thought when doing something or when talking?

become easily confused or distracted?

other

if other, please describe:

Processing Speed Difficulties

Do you find...

that it takes longer to process information?

that your thoughts are slower?

other

if other, please describe:

Speech/Language Problems

misname objects?

have trouble finding words?

notice a change in quality of you speech?

if yes, please check below:

Slurred? Louder/Softer? Rambling? Jump from one topic to the next?

have trouble understanding what others are saying?

have trouble expressing yourself with words?

have problems spelling?

other

if other, please describe:

Reasoning and Nonverbal

Do you...

have trouble with multiple-step activities?

have difficulty recognizing familiar objects or people?

have trouble making change with small sums of money?

have trouble making decisions?

other

if other, please describe:

Memory

Do you have difficulty remembering...

where objects are placed (e.g. keys)?

that appliances are on?

appointments?

to take medications?

to pay bills?

activities you were just doing?

plans you made for the day?

what you just read?

where you are going when driving or walking?

events that only happened minutes or hours ago?

events that happened long ago (months, years)?

how to perform an activity you used to know how to do quite well?

other

if other, please describe:

Do hints or clues help you remember?

Yes, they help.

No, they do not help.

Emotional Symptoms and Behavior Difficulties

if other, please describe:

Have there been any stressors in your life (illness, death, operation, accident, separation/divorce, changing jobs, family financial problems, remarriage, sexual trauma, stress due to litigation)?

Physical Symptoms

Please decribe where you are experiencing reduced strenth, pain, or reduced sense of touch, if applicable.

Daily Functioning

Please note how much assistance you now require to perform the following daily tasks on a scale of 1 to 10 (1 being completely independent, 5 being moderate assistance, and 10 being maximum assistance) in the boxes below.

Psychiatric History

Please note if you have any of the following psychiatric disorders and the year they were diagnosed.

Please specify if Yes/No if you are receiving medication treatment for diagnosed disorders and specify medication in the medication section later in this form.

Anxiety Disorders

Current

Past

Year