ADULT NEUROPSYCHOLOGICAL INTAKE EXAM BASIC DEMOGRAPHICS
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1 Division of Behavior Medicine CLINICAL NEUROPSYCHOLOGISTS Jeanne T. Schmerler, PsyD Megan O Connor, PhD Wes Houston, PhD Audrey Greene, PsyD Norwood Office 4805 Montgomery Rd., Suite 210 Norwood, Ohio Direct: (513) Fax: (513) ADULT NEUROPSYCHOLOGICAL INTAKE EXAM BASIC DEMOGRAPHICS NAME: DATE: Start time: Stop time: Hours: REFERRAL SOURCE: EXAM TYPE: Forensic Civil Forensic Criminal Worker's Comp Disability Competency Medical Other Tentative Dxs: 1) 2) 3) REASON FOR REFERRAL: Age: DOB: / / Handedness: R L Mixed Occupation: Onset of injury or illness: / / Date last worked or disabled: / / First injury? N Y Date: / / Describe: Education: Number of years Military history: N Y Legal History: N Y College or Tech school: Race: Afro-American Asian American Indian White Hispanic Other Marital Status: S M Div Sep Wid Other Involved in Litigation: N Y Attorney name & phone number: Notes: Riverhills Neuroscience Neurology Interventional Neurosurgery Pain Management Behavioral Medicine Diagnostics Research
2 INFORMED CONSENT OBTAINED? N Y If no, reason: PATIENT'S CHIEF COMPLAINTS? ACCIDENT/ILLNESS HISTORY: CURRENT TREATMENT & TREATING PROFESSIONALS (who, what, when started, effectiveness) CURRENT MEDICATIONS (what, dosage, frequency, when started, effectiveness)
3 PAST MEDICAL HISTORY (check where applicable) Arthritis Blackouts Blood Disorder Brain Injury Cancer Cardiac Disease CVA Diabetes Epilepsy No previous illnesses Falls Hearing Deficits Hypertension Hypoxia Lung Disease Motor Deficits Renal Disease Thyroid Disease Visual Deficits Other (describe) PAST SURGERIES: PRIOR DIAGNOSTIC TESTING (check where applicable) MRI Date Results EEG Date Results Labs Date Results PAST PSYCH HISTORY Psych outpatient tx: N Y # times: Diagnosis: Psych inpatient tx: N Y # times: Diagnosis: Family psych hx: N Y Describe: ETOH/SUBSTANCE ABUSE HISTORY Alcohol use: N Y Average # drinks per week # of times DUI/DWI Treatment: Substance abuse: N Y Type, frequency, main choice, last used Caffeine intake: N Y Type/amount Smoking: N Y Amount If quit, when? / / Neurotoxin exposure: N Y Type & date:
4 PAIN ASSESSMENT Headaches: N Y Location Frequency: Intensity (0 to 10) What triggers? What relieves? Musculoskeletal: N Y Location Frequency: Intensity (0 to 10) What triggers? What relieves? Total pain level now (0 to 10): DEVELOPMENTAL PROBLEMS Problems with Mom's pregnancy: N Y Describe: Problems with Mom's delivery: N Y Describe: Apgar Rating: Developmental problems: N Y Describe: Childhood history of (check where applicable) Abuse Head Injury High Fevers Motor Problems Seizures Speech Problems FAMILY HISTORY (record all pertinent history for nuclear family including age, health status, medications, psych status, work or educational status and cause of death, if applicable) Father: Mother: Brother(s): Sister(s): Married: N Y How long: Relationship: Supportive Neutral Stressful Destructive Divorced: N Y # of times: When Why Custody problems Comments: Children: N Y Names & ages: Hx behavioral problems: N Y Type: Hx educational problems: N Y Describe:
5 LEGAL HISTORY Arrests: N Y Reason: Convictions: N Y Charges: EDUCATIONAL HISTORY Highest grade completed: Graduated or GED Year High school attended: Discipline problems N Y College or Tech school attended: GPA: Reasons for leaving school: Best subject: Grade: Worst subject: Grade: Failed any grades: N Y Which: Repeat any grades: N Y Which: History of LD: N Y Describe: History of ADD: N Y Treatment: VOCATIONAL HISTORY Employed: N Y Length of time in job: Disability date: Job duties: Job problems: Promotions/Problems with other jobs: Past job history (what, where, when, reason for leaving) MILITARY HISTORY Military: N Y Service Branch: Rank at discharge: Job type: Combat experience: N Y Describe: Service connected disability: N Y Describe: CURRENT FINANCIAL RESOURCES
Pinkston Psychology, LLC Ph. (318) Fx. (318) Completed this form Patient Spouse Parent Other
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New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Seminar Information Page
OFFICE USE ONLY Height, Weight & BMI Insurance Primary Care Phys. Medical Problems Surgical History Med List & Dosage Allergies & Fam Hist. CDS (city, washoe, wcsd or reno diocese) OFFICE USE ONLY Pt #
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:
Practice: Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters, reminders, statements, etc. Address: City: State:
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: Address: Relationship: Address:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: ( ) Marital Status: Married Single Divorced Widowed Cell Phone: (
9834 Genesee, Suite 223B La Jolla, CA Phone Fax
PATIENT HEALTH QUESTIONNAIRE (Page 1) 9834 Genesee, Suite 223B La Jolla, CA 92037 Phone 858-277-7123 Fax 858-277-3470 ***Please fill out completely. Failure to do so may delay payment of your claim. Indicate