BACKGROUND QUESTIONNAIRE (INFORMANT)

Transcription

1 BACKGROUND QUESTIONNAIRE (INFORMANT) The following is a questionnaire about someone you know who plans to participate in a neuropsychological assessment or capacity assessment. The information you provide here will be integrated with the assessment results to provide a complete picture of the individual as well as any problem areas. Please fill out this questionnaire as fully as possible. Additional details may be put on the reverse side, if needed. Your name: Today s date: Your contact details: Your relationship to adult being assessed: Name of adult: Date of birth: Age: Gender: He/She resides in a(n): house/condo apartment supported living extended care facility Address: The adult (check one): lives alone with spouse others (specify): Main telephone: ( ) Other telephone: ( ) Birthplace: If not born in Canada, in what year did the adult immigrate to Canada? First language learned: Preferred language at home: Is the adult fluent and comfortable speaking or holding a conversation in English? yes no Is the adult fluent and comfortable reading and writing in English? yes no Does the adult wear eyeglasses? yes no If yes, is the prescription up to date? yes no Does the adult have hearing aids? yes no If yes, do the hearing aids work properly? yes no What is his/her dominant hand (i.e., usually the hand used for writing)? right left both Does the adult have an active substitute decision-maker or legal guardian? yes no Briefly describe your main concern(s) regarding the adult: What specific questions, if any, would you like answered by this evaluation? 1) 2) 3)

2 Cognitive concerns: In the last 5 years, have you noticed a change in the adult s memory or thinking? yes no If yes: When did the problem first appear? Did it begin slowly (months/years) or quickly (hours/days)? Was there an event or injury that caused it? Is the problem consistent (present most days) or transient/fluctuating? Over time, has the problem (circle one): improved remained stable gotten worse Please check all of the concerns below that apply to the adult and record when each started. Symptom Date/year started Forgets events that happened over ten years ago or gaps in distant memory Forgets recent conversations or events (e.g., what he/she did yesterday) Forgets where to put things or misplaces items more often (e.g., keys, glasses) Forgets scheduled appointments or forgets things that he/she intended to do Has trouble retrieving the names of friends, relatives, or acquaintances Has trouble recognizing objects, familiar places, or the faces of familiar people Relies more on others to provide cues or reminders due to forgetting Relies more on writing things down (e.g., lists or calendar) due to forgetting Forgets how to do tasks or use items (e.g., appliances, TV, tools, toothbrush) Has difficulty with new learning or figuring out how to do something new Forgets the date, month, or the year (off by more than just a few days) Has trouble remembering where he/she is (e.g., where they live or their location) Has trouble staying alert or level of alertness fluctuates hour to hour, or day to day Has difficulty concentrating or staying focused Easily loses his/her train of thought or frequently appears to go blank Gets easily distracted or has trouble sustaining attention over time Has difficulty doing more than one thing at a time (i.e., shifting/dividing attention) Gets confused about the situation or what is going on around him/her Has word-finding difficulties, substitutes words, or hesitates more when talking Has difficulty speaking (e.g., trouble pronouncing words, slurring, low volume) No longer participates in conversations, or talks much less than usual Has difficulty understanding what others say or needs words/ideas explained Has difficulty with reading or trouble understanding what he/she reads Has difficulty or changes in writing (not due to arthritis, injury, or weakness) Has difficulty with math (e.g., trouble counting, adding, subtracting, multiplying) Has difficulty solving problems that he/she used to do or that most others could do Has difficulty planning ahead (e.g., planning a meal, trip to the doctor, vacation) Has difficulty doing things in the right order (i.e., sequencing) Has difficulty getting started on new tasks or trouble completing what he/she starts Has difficulty making sound decisions on their own or seems more indecisive Has difficulty building or assembling things or difficulty drawing and copying Has difficulty finding his/her way around familiar areas or has been lost Seems mentally slower (e.g., he/she takes longer to think or answer questions) Has a tendency to mix up left and right Provide details or list any other changes in his/her thinking that you have noticed (use back of page if needed):

3 Physical and emotional health concerns: Have you noticed a problem or change in the adult s mood or personality lately? yes no How would you describe his/her recent mood? Have you noticed a problem or change in the adult s physical health lately? yes no How would you describe his/her recent state of health? Please check all of the concerns below that apply to the adult and record when each started. Symptom Date/year started Vision problems (e.g., colour blindness, blurred or double vision, legally blind) Hearing problems (e.g., diminished hearing, ringing in your ears, fully deaf) Smell or taste problems (e.g., difficulty detecting pleasant or unpleasant odours) Tingling, burning, numbness, or unusual sensations in any part of the body Mobility problems or needing a cane, walker, or wheelchair to ambulate Has fallen in the last year; circle one: once, occasional (2-3), recurrent (4 or more) Decreased balance or seems less steady on their feet Decreased coordination (e.g., clumsy, dropping things, or bumping into things) Tremor or shakiness; specify body parts affected: Tics or unusual movements and/or vocalizations Seems weak all over (i.e., generalized weakness) Seems weak on one side or one part of the body; specify part: Faints or blacks out Dizziness or light-headedness Nausea or vomiting Bladder/bowel problems (e.g., incontinence, constipation, often getting up at night) Headaches or head pain Pain elsewhere in body; specify where: Low energy or seems tired much of the time, or unusually high energy Change in appetite; circle one: loss of appetite or increased appetite Change in weight; specify: amount of loss ( ) or amount of gain ( ) Trouble falling asleep or staying asleep, or not feel rested upon waking Sleeps too much or more than usual, seems excessively tired during the day Other sleep concerns (e.g., excessive movements during the night, nightmares) Seems sad or depressed more days than not, or exhibits no feelings at all Less interest in activities or less pleasure from activities he/she previously enjoyed Seems hopeless and/or has thoughts that life is not worth living anymore Seems irritable, easily upset, frustrated, or more argumentative Seems angry or acts in an aggressive manner (e.g., yelling, hitting others) Seems on top of the world with a lot of energy and/or racing thoughts Seems anxious, tense, or nervous; or experiences a great deal of stress Seems impulsive or less inhibited (e.g., takes more risks, acts inappropriately) Withdraws more from social activities Clutter at home with pattern of acquiring and not discarding items (i.e., hoarding) Hears or sees things that other people cannot perceive or do not notice Seems more suspicious or mistrustful of others Provide details or list any other physical health or mood concerns (use back of page if needed):

4 Day-to-day functioning concerns: In the last 5 years, have you noticed a decline in the adult s functioning at work or home? yes no Below are changes in day-to-day tasks that some people experience. Please check all that apply to the adult. When did you first Compared to 5 years ago, does he/she have more difficulty or need assistance with: notice a change? Driving or operating a vehicle safely; if he/she never drove, check here: Using other forms of transportation (e.g., arranging taxis, using public transit) Managing finances (e.g., pay bills, write cheques, balance chequebook, pay taxes) Managing medications (e.g., forgetting to take pills on time, mixing up pills) Preparing meals (e.g., more cooking errors, trouble following recipes, not eating) Shopping (e.g., forgetting items to purchase or buying things they already have) Using the telephone, television, computer, or household appliances Cleaning their home (e.g., vacuum, dust, wash dishes) or cleaning the laundry Performing household maintenance and/or yardwork Participating in social activities (e.g., playing bridge, socializing with others) Performing work-related duties (if not retired) or normal volunteer activities Getting dressed and managing self-care (e.g., brush hair, brush teeth, shave) Taking a bath or shower Getting up from beds or chairs or mobilizing without aids Using the toilet Feeding (e.g., needing food cut up) Provide details or list any other day-to-day changes you have noticed (use back of page if needed): Have you any concerns about the adult living alone or their safety at home? yes no Does the adult forget to turn off stove burners, irons, or water taps? yes no Are you aware of others who have tried to take advantage of the adult? yes no Does the adult have any support such as Home Care service or hired housekeeping? yes no Assessment and treatment: Please list all of the adult s current medications and dosages (use back of page if needed): Please list details of any previous neuropsychological/psychological assessments, psychological counselling, or psychiatric treatment: Dates of any brain imaging (CT, MRI, PET, SPECT), EEG, or neurological examinations: Date of last vision exam: Date of last hearing exam: Name of adult s family physician:

5 Medical, psychiatric, and developmental history: Please check all conditions that the adult has now or has been diagnosed with in the past. Condition First noticed or diagnosed Dementia (e.g., due to Alzheimer s disease or other disease) Brain injury or loss of consciousness (e.g., accidents, sports injury, fall) Seizures or epilepsy Cerebrovascular accident (stroke) or transient ischemic attack (TIA) Diabetes; specify: insulin-dependent or non-insulin dependent High blood pressure (hypertension) or low blood pressure (hypotension) High cholesterol (dyslipidemia) Heart disease (e.g., coronary artery disease, myocardial infarction) Lung disease (e.g., chronic obstructive pulmonary disease, asthma) Liver disease (e.g., cirrhosis of the liver, hepatitis) Kidney disease (e.g., chronic renal disease, kidney failure) Thyroid disease (e.g., hypothyroidism, hyperthyroidism) Sleep apnea (i.e., periods of not breathing while sleeping) Movement disorder (e.g., Parkinson s disease, Huntington s disease) Multiple sclerosis Cancer or cancer-treatment (i.e., surgery, radiation, chemotherapy) Brain infections (i.e., meningitis, encephalitis) Other infections/viral conditions (e.g., urinary infections, AIDS/HIV, STD) Chronic fatigue, myalgic encephalomyelitis, systemic exertion intolerance Chronic pain or fibromyalgia Arthritis Major surgery in the last 5 years; specify: Problems related to alcohol use Problems related to drug use (e.g., marijuana, cocaine, etc.) Problems related to medication overuse (e.g., narcotics) Problems with gambling or other addiction; specify: Exposure to toxins (e.g., lead, mercury, solvents, pesticides, chemicals) Depressive disorder (e.g., chronic or recurrent depression) Bipolar disorder (i.e., manic-depression ) Anxiety disorder (e.g., generalized anxiety, panic attacks, social phobia) Schizophrenia, delusional disorder, or other psychotic disorder Obsessive compulsive disorder Post-traumatic stress; specify trauma: Learning difficulties in school (e.g., reading, spelling, mathematics) Attention problems in school (e.g., distractibility, hyperactivity, ADHD) Developmental delays or intellectual disability Problems related to birth/delivery (e.g., oxygen deprivation) Fetal alcohol syndrome (check if mother used alcohol during pregnancy) Other condition: Family history: Provide details about the adult s biological relatives who may have had any of the conditions listed above.

6 Adult s history: Marital status: single married common-law separated divorced widowed If married, name of spouse: Year married? Previous marriage details: Names and ages of any children: Last grade completed (circle): or GED Average grade (circle): A B C D F Best subject: Worst subject: Did the adult ever fail a course or repeat a grade in school? If so, which one(s) and why? Post-secondary (degrees and school attended): Employment status: retired; when did he/she retire? employed off work or not employed Primary occupation: Years worked: Previous jobs: Current sources of income: Current use of alcohol/recreational drugs (specify substance, amount, and frequency of use): Briefly list the adult s interests, hobbies, or activities: Briefly list any recent stressors in his/her life (e.g., deaths, financial difficulties, relationship concerns): Briefly list any past physical or emotional abuse the adult may have experienced (e.g., physical assault): How would you describe the adult s quality of life at this time? If he/she served in the military, provide details including branch, dates of service, rank, combat, injuries, etc: Is the adult involved in any litigation or disciplinary action? Does the adult have a Personal Directive? yes no An Enduring Power of Attorney? yes no Please list any other concerns or specific accommodations the adult may need for this evaluation: Thank you for completing this questionnaire! Please return the completed form to Dr. Frerichs.