Patient Name: Date of Birth: Date of Visit: Age: Referred By: Please complete this form before your visit to the neuropsychologist.
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1 Patient ame: Date of Birth: Date of Visit: Age: Referred By: Form completed by: Please complete this form before your visit to the neuropsychologist. What is the reason for today's visit? What are your goals/hopes for today's visit? Have you had changes in your memory, thinking or behavior? es If the patient s family or friends have noticed changes then they should fill out this section of the form. When were the symptoms first noticed (month/year)? What was the first symptom(s)?: Progression has been: Rapid (< 2 months) Gradual (6mos-years) Stepwise o COGITIVE ever (does not occur) Rare (less than monthly) Occasional (every week) Frequent (daily / almost daily) ot knowing date / time ot knowing where they are Short term memory loss Trouble maintaining focus Difficulty controlling impulses Difficulty with organization / planning 1
2 Patient ame: Date of Birth: MR: Trouble making decisions Poor judgment (dangerous actions, excess spending, etc.) Difficulty with word finding Difficulty understanding conversations Trouble writing Difficulty with reading Getting lost BEHAVIOR Delusions (false beliefs such as paranoia or infidelity of a spouse) Hallucinations (seeing, hearing, etc. things that aren t there) Agitation /Aggression (refusing to cooperate, yelling, hitting) Depression / Sadness ever (does not occur) Rare (less than monthly) Occasional (every week) Frequent (daily / almost daily) Anxiety / ervousness Apathy / Indifference (lack of interest in the world or others) Disinhibition (impulsive, socially unacceptable behavior) Irritability (moody, gets angry easily) Motor behavior (pacing, rummaging, fidgeting, etc.) Sleep issues (insomnia, confusing day/night, fighting during sleep) Appetite (decrease, increase, change in food preference) MEDICAL / SURGICAL (use back of sheet if necessary) Are you right handed, left handed, or ambidextrous? (Please circle) Do you have a history of head and/or brain injury? es o 2
3 Patient ame: Date of Birth: MR: Have you ever had a stroke or TIA (transient ischemic attack)? es o Have you ever had a seizure? es o Have you ever had a CT or MRI scan of your brain? es o MEDICAL Illness ear it started SURGICAL Type of Surgery ear MEDICATIOS Current Medications: Drug ame Dosage Times per day Length of use Over-the-Counter (Vitamins, supplements, laxatives, pain relievers, allergy medicine, cough medicine, etc.) ame Dosage Times per day Length of use 3
4 Patient ame: Date of Birth: MR: REVIEW OF SMPTOMS Have you experienced any of the following problems: General: Weight change Fatigue / malaise Fever / Chills Pain: Local: (where): Generalized Skin: Rash / itching Hives Change in hair or nails Sweating too much / too little Eyes: Wear glasses / contacts Double vision Blurred vision Visual loss Dry eyes Cataracts Glaucoma Ears: Hearing loss Ringing in ears Dizziness (Vertigo) ose, Mouth and Throat: Hoarseness Dry mouth Loss of sense of smell Loss of sense of taste Ear / Throat / Tooth Pain Heart: Fainting Low blood pressure High blood pressure Chest pain Slow / Fast heart rate Irregular heart beat Cold feet / hands Leg swelling Lungs: Shortness of breath Chronic cough Gastrointestinal: Change in appetite Difficulty swallowing Stomach pains / heartburn ausea/vomiting Diarrhea Constipation Liver disease Fecal incontinence Metabolic: Excess thirst Heat / cold intolerance Change in sexual interest: increased / decreased Hair loss Change in voice Thyroid problems High cholesterol /lipids Genital-urinary: Difficulty urinating ighttime urination Urinary urgency Urinary incontinence / leakage Urinary tract infection (recent) Erectile dysfunction Hematologic Anemia Swollen lymph nodes Easy bleeding Easy bruising Musculoskeletal: Muscle pain Joint pain Back pain Fibromyalgia ighttime muscle cramps eurological: Headaches Muscle weakness umbness / tingling Loss of balance Falls Slow movements Tremor Change in handwriting Learning disability or ADHD Insomnia Tired in the morning Falling asleep during day Bedtime: Wake time: Snoring Stop breathing Moving during sleep Psychiatric: Anxiety (nervousness) Depression (sadness) Previous psychiatric hospitalization Hallucinations Delusions Compulsive behavior History of suicide attempt Other: 4
5 DAIL FUCTIOIG Do you drive? es o ever Drove If yes, have you had any tickets or accidents in the last year? es o Have any concerns been expressed about your driving? es o If you are not driving, when did you stop? Why? TASK Independent eeds Some Assistance or Cueing Taking public transportation Shopping Housekeeping Meal preparation Handling finances (banking, investing, budgeting) Managing money (making change, paying bills) Taking Meds Using the telephone Doing laundry Socializing Getting dressed Bathing or showering Grooming (teeth, hair, shaving) Toilet hygiene Feeding self (check one in each category / row) eeds Much Assistance Unable to Do ever did this task HEALTH HABITS Do you currently or did you ever smoke? es o If yes, how many cigarettes per day? For how many years? If you quit smoking, when? Do you drink wine, beer or liquor? es o What and how often? Has anyone ever been concerned about your drinking? es o 5
6 Have you used other drugs / substances? es o What and how often? Do you have any regular form of exercise? es o What and how often? With whom do you live? SOCIAL HISTOR (alone, spouse, child, other family, other-not family) Do you get any help from family or friends in your home? es o If yes, please describe: Are you using any agency or services for help at home? es o If yes, please describe: Where do you live? Own home Senior apt. Condo Apartment Assisted Living ursing Home If you live at a care facility, please list contact person there. ame: Phone: Marital / Partnership Status: Married Domestic partner Widowed Divorced/Separated Single/ever married Other How long? How long? How long? How long? How many children do you have? Are you in regular contact with your children? es o How much education did you complete? (Please circle) Less than 8th grade 8 th grade Some high school High school Some College College Graduate Graduate School Post-graduate What kind of grades did you get in school? (Please circle) Below Average Average Above Average Did you ever use special education services? es o Did you ever repeat a grade? es o 6
7 What is / was your Primary Occupation: If retired, for how long? If still working, where? How many hours per week? Have you received any negative (performance related) feedback in the workplace? es o Other significant past occupations: 7
8 Continue on the back if necessary. FAMIL MEDICAL HISTOR Include any serious medical problems and if anyone in the family had a history of Alzheimer s disease, other types of dementia, ALS or motor neuron disease, stroke, seizures or serious psychiatric illness. Family Member Living? Mother Father Brothers/Sisters (list): Age now or at death Children, Biological only (list): Cause of death List Medical/eurological/Psychiatric Problems current or in the past (e.g. high blood pressure). Include age of onset if known. Add information about grandparents, aunts/uncles, cousins if necessary: 8
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