NEUROPSYCHOLOGY APPOINTMENT CHECKLIST
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- Gervase Booth
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1 NEUROPSYCHOLOGY APPOINTMENT CHECKLIST Most neuropsychology appointments last 4-6 hours. Typically, evaluations last from 8:45 a.m. until approximately 4 p.m., with a 1-hour break for lunch. During the visit you and any accompanying family members will first meet with the doctor, followed by paper-and-pencil and computerized tests of mental abilities and psychological functioning. None of the tests are painful, and most patients find them enjoyable and interesting. Because you will be with us most of the day, please complete the below checklist to ensure you are prepared. What to do beforehand: Get a good night s sleep Eat breakfast Take medications as usual No alcohol or other substance use for 48 hours prior Give yourself plenty of time for travel and parking in the morning What to bring with you: Completed Background Questionnaire (on following pages) If possible, a trusted family member or close friend who is familiar with your daily activities. It is extremely helpful for you to have an extra set of ears and for us to better understand your situation. They will only need to stay nearby for the first hour. Insurance card and photo ID Eyeglasses/contacts (please bring, even if you don t normally wear them) Hearing aid(s) Any medications you need to take during the day Lunch (or feel free to grab lunch in our café) CD of brain CT/MRI scan AND radiologist report, if outside of AAMC system Results of any previous neuropsychological evaluation(s) We look forward to seeing you!
2 CONFIDENTIAL Page 1 of 6 NEUROPSYCHOLOGY BACKGROUND QUESTIONNAIRE Instructions: Please answer all questions as accurately and completely as possible. You will have a chance to discuss answers in detail with the doctor. Your family or friends can help if needed. Thank you! 1. GENERAL INFORMATION: Questionnaire completed by [if different than patient]: Relationship to patient: Patient Name: Date of Birth: _ Age: Gender: Race/Ethnicity: Native Language: Highest level of formal education completed: Handedness: Right / Left Home address: Home phone: Cell phone: Work phone: Referring physician: Have you ever had a neuropsychological evaluation before? If YES, name of doctor: Date: Have you had a recent CT or MRI of the brain? If YES, and it was outside of AAMC, please bring CD of scan and doctor s report, or have your records sent to us. Does the purpose of your evaluation relate to legal action or a disability application? If YES, please describe: 2. CURRENT QUESTIONS / PROBLEMS: Primary reason for having this neuropsychological evaluation (e.g., types of cognitive problems patient is experiencing, related to medical diagnosis or injury, etc.): Date of onset of above problem/condition: What question(s) would you like answered by this evaluation?
3 A. Cognitive Problems: Please check any that currently give you difficulty: Mental processes slowed down Trouble concentrating or easily distracted Trouble thinking of words you want to say Trouble remembering what to buy at store Forgetting people s names Losing things Forgetting recent events or experiences CONFIDENTIAL Page 2 of 6 Trouble recalling experiences or things you learned long ago Getting lost or difficulty using maps/gps Trouble solving complex problems Disorganized Acting impulsively Other: When did you first become aware of these problems? Did these problems come on gradually or suddenly? What do you think caused them? Since they started, have they become worse, stayed the same, or improved? B. Problems with Independence of Daily Living: Please check any activities you cannot do on your own: Bathing Using toilet Brushing teeth Dressing/undressing Walking Being at home alone Preparing food Grocery shopping Doing laundry Vacuuming Using telephone Yardwork Managing finances Managing medications Other: Currently driving? If NO, what is the reason? Date stopped driving: C. Psychological, Emotional, and Interpersonal Difficulties: Please check any you have recently experienced: Large or rapid fluctuations in mood Anxious, fearful, nervous, or difficulty relaxing Depressed mood Tendency to be self-critical or perfectionistic Embarrassed by your limitations Feel like a burden on others Feel like giving up Often irritable or frustrated Angry or have difficulty controlling temper Difficulty trusting others Seeing, hearing, smelling, or feeling things that weren t really there Repetitive thoughts that bother you Repetition of behaviors that are not really necessary Serious conflict between family members Marital problems Other: D. Other Relevant Problems: Please check any symptoms you may be having now or recently: Headaches Eye problems Blurry vision Double vision Drooping of eyelid Hearing problems Reduced sense of smell Unusual smells Reduced sense of taste Unusual taste in mouth Problems swallowing Weakness Problems walking Poor balance Clumsiness/falls Tremor Problems speaking Bowel/bladder incontinence Diarrhea Weight loss or gain Pain
4 CONFIDENTIAL Page 3 of 6 3. FAMILY HISTORY: Please tell us about your parents & siblings, if known. Name Sex Alive? Age (or age at death) Education (highest level completed) Occupation Health problems? (or cause of death if deceased) Parents: Siblings: Are all of the above individuals biologically related to you? If NO, who? Please check any of the following conditions in your immediate or extended blood-related family. Dementia/Alzheimer s Seizure disorder Parkinson s disease Huntington s disease Multiple sclerosis Stroke Brain tumor Other neurological disease Psychiatric hospitalization Schizophrenia Bipolar disorder Depression or suicide Anxiety or panic disorder Alcohol/drug addiction Other psychiatric problem ADD/ADHD Autism/Asperger s Intellectual disability 4. EARLY DEVELOPMENT: Where were you born? Where were you raised? Who primarily raised you? Please check if you had any of the following in your childhood: Premature birth Problems during mother s pregnancy with you Birth problems or birth trauma Late to walk, talk, or start school Speech therapy Learning disability Attention problems Behavior problems School suspension or expulsion Individualized Education Plan (IEP) Special education classes Any extra help or tutoring in school Grade failure If so, which grades? Grade skipping If so, which grades? _
5 CONFIDENTIAL Page 4 of 6 5. EDUCATION: Circle highest grade completed: AA BA/BS MA/MS Doctorate Typical academic grades last few years of high school: A s B s C s D s F s High school: Public OR Private GED? If YES, year: Any trade school or technical training: Undergraduate college or university attended: SAT score: Major: GPA: Degree: Year: Graduate college or university attended: Graduate major: GPA: Degree: Year: 6. OCCUPATION: Are you currently working? If NO, are you retired? or out of work? Since when? Current or most recent job title: Company/organization: How long with this company? Have the problems for which you are being evaluated influenced your ability to do your work? If YES, please give details: Other major types of employment you have had: 7. HOME LIFE: Current marital status: Single Married Divorced Separated Widow/widowered Number of times married: Years married to current spouse: Spouse s name: Spouse s age: Spouse s highest level of education: Spouse s occupation: Spouse s health problems: Please tell us about your children: Child s name Sex Age Highest education Occupation Health problems? Who lives with you in your residence? What do you like to do most in your free time? Religion: Do you attend religious services regularly?
6 CONFIDENTIAL Page 5 of 6 8. MEDICAL HISTORY: These may affect or involve brain functioning. Please check any you have ever had: Concussion Traumatic brain injury Spinal cord injury Deprived of oxygen Near-drowning episode Sleep apnea High or low blood pressure High cholesterol Heart problems Diabetes or prediabetes Transient ischemic attack or mini-stroke Stroke Carotid artery problems Migraine or ocular migraine Vascular malformation Aneurysm Seizure Meningitis Other infection of the brain Hydrocephalus Multiple sclerosis Parkinson s Disease Delirium Dementia/Alzheimer s Any cancer or tumor Exposure to toxic chemicals Exposure to radiation Vitamin B deficiency Eating disorder HIV infection Hepatitis A/B/C Thyroid disease Rheumatoid arthritis Lupus Fibromyalgia REM sleep disorder Insomnia Other: Any other major illnesses, with dates: Any surgeries, with dates: Any hospitalizations, with dates: When was your last eye exam? 9. MEDICATIONS: Please list your current medications and vitamins, or attach a list. Medication/Vitamins Single dose How often? Reason Who prescribes? Start date
7 CONFIDENTIAL Page 6 of PSYCHIATRIC HISTORY: 1. Have you ever been diagnosed with a psychological or psychiatric disorder? If YES, what was the diagnosis? 2. Have you ever seen a: If YES, when, and what for: Psychiatrist Psychologist Social worker Individual counselor/therapist Marital counselor/therapist 3. Have you ever had a psychiatric hospitalization? If YES, when? 11. SUBSTANCE USE / LEGAL: 1. Do you currently use tobacco? If YES, how much? pack/day Since when: 2. If you used to use tobacco, when did you stop? How long did you use tobacco before you quit? 3. How much alcohol do you drink? 4. If you used alcohol only in the past, when did you stop? 5. Were you ever a heavy drinker in the past? If YES, when: 6. Have you ever been arrested for DUI/DWI? If YES, when: 7. Have you ever been arrested for anything else? If YES, for what? 8. Have you ever attended a meeting of Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)? 9. Have you ever used any recreational drugs, including marijuana? If YES, which one(s) and when? 10. Have you ever taken prescription pain medication that wasn t prescribed for you, or at a dose higher than prescribed? If YES, which ones and when? 11. Have you ever been involved in a lawsuit, either as plaintiff or defendant? 12. ADDITIONAL INFORMATION: Any other information important for us to know? Thank you for taking the time to complete this questionnaire. The information you have provided will be extremely helpful in conducting your evaluation and answering your questions, as well as your referring doctor s questions. AAMG Neuropsychology Specialists CBQ v1.1
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Department of Geriatric Medicine Pre-Visit Questionnaire for Dementia Evaluation Name: MR#: Imprint Area This questionnaire is to be filled out by someone who knows you well. Name of Person completing
SANDSTONE PSYCHOLOGICAL PRACTICE
SANDSTONE PSYCHOLOGICAL PRACTICE Christina L. Aranda, Ph.D. & Janell M. Mihelic, Ph.D. CONTACT INFORMATION New Client Questionnaire Name: Date: Date of Birth: Age: _ Address: Preferred Phone Number: Type:
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
To help you prepare for your doctor's visit, the Alzheimer Society has developed the following list:
The Alzheimer Society has a tool kit to help you prepare for a conversation with your doctor or health provider about your concerns and questions about a possible dementia diagnosis. Symptoms of dementia
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM Today s Date PERSONAL DATA Legal Name Preferred Name Age Date of Birth Height Weight Home Address City State Zip Home phone ( ) Business Phone ( ) Cell
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
Please complete this form before your Doctor visit. We will review this together and make any changes needed.
1 Medical History Please complete this form before your Doctor visit. We will review this together and make any changes needed. Name Date of Birth Date of visit What is your height? weight? Medical History,
LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK Date. Personal History Information
1 LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK 74074 405-707-9600 Date Personal History Information Client's Name Referred By Address Phone City/State/Zip Birthdate Age Occupation Employed by Social
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
PRE-VISIT QUESTIONNAIRE
INSTRUCTIONS FOR COMPLETING Please answer the following questions about your health and history. Although this form is lengthy, it is designed to be very thorough. Completing this information before your
ADULT History Form (To be filled out by the person seeking treatment)
1 ADULT History Form (To be filled out by the person seeking treatment) Client s Name Date: SS# - - DOB: / / Age: Person completing this form: Client Other: (give name) Who referred you to Namsate Counseling?
PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: Internet: Fax:
PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: 412-221-7640 Internet: www.davidprovenzanomd.com Fax: 412-490-9850 301 Ohio River Boulevard, Suite 203 Edgeworth Medical Commons Sewickley, PA 15143 INITIAL
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process.
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process. PATIENT CONTACT INFORMATION Name Age Date of birth Phone ( ) Mailing
Health History Form Name: Age:
Health History Form Age: Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are uncomfortable with any question, do not
Outpatient Rehabilitation Services Speech-Language-Cognitive Therapy Adult Patient Intake Questionnaire
Outpatient Rehabilitation Services Speech-Language-Cognitive Therapy Adult Patient Intake Questionnaire Name: Today s Date: Referring Physician: Neurologist: Date of Birth: Age: Primary Dr: Physical Therapist:
Child/ Adolescent Questionnaire
Oconee Center for Behavioral Health 1360 Caduceus Way Building 400, Suite 102 Tel 706-286-8442 Fax 706-310-6907 Child/ Adolescent Questionnaire Patient s Name: Date of Birth: / / Patient s Birthplace:
CHEMICAL USE EVALUATION INTERVIEW. A. Demographics
CHEMICAL USE EVALUATION INTERVIEW DATE OF EVALUATION A. Demographics COMPANY NAME: NAME ADDRESS PHONE: MARITAL STATUS SOCIAL SECURITY # DATE OF BIRTH AGE GENDER RACE/ETHNICITY VALID DRIVER S LICENSE: YES:
PART I: GENERAL PATIENT INFORMATION. Family Physician: Address: City: State: Zip: Date of Birth: Age: Male Female
THE MEMORY CENTER OF NORTHEASTERN NEW YORK EMPIRE NEUROLOGY, P.C. 1182 TROY-SCHENECTADY ROAD, STE 203 LATHAM, NY 12110 P: (518) 389-6876 / F: (518) 785-5000 In order to obtain the most complete information
A New Tomorrow Behavioral Health Services
A New Tomorrow Behavioral Health Services Tara L. Corbett MS, LPC Jenais Y. Means MA, LPC-I Linda L. Leech PhD, LPC, LPC-S Natasha Moseng MS, LPC-I 2635-A Hardee Cove, Sumter, S.C. 29150 Phone: (803) 883-4981
SOAR Referral. RETURN OR FAX: ATTENTION Worcester County Core Service Agency at Referring Agency: Referral by: Contact information:
SOAR Referral Client Name: Date: Gender: M F Race: Social Security Number: DOB: Does client have a birth certificate and valid ID? YES NO If yes please send copies along with referral. If no would client