Age Date of Birth Sex: Male Female. Ethnic or Racial Background Primary Language Secondary

Transcription

1 Although this form is several pages long, very little writing or description is required. Most responses require checkmarks only. By having this form completed before diagnostic and treatment sessions, we will be better able to make treatment decisions and recommendations. Patient s Name Date Age Date of Birth Sex: Male _ Female _ Ethnic or Racial Background _ Primary Language Secondary_ Hand used for writing (check one) Left Right This form has been completed by: Patient _ Other If NOT completed by the patient, please provide the following information: Name _ Relationship to Patient _ Primary Medical Concern _ What are your goals for treatment/evaluation? Have you ever had a prior psychological or neuropsychological evaluation? Yes _ No If prior eval: Year _ Name of Psychologist Have you had a traumatic brain injury or motor vehicle accident? Yes No Date: _ Time: _ Location: _ Please check each symptom if it is a NEW symptom (beginning after the accident or onset of medical problem) or an OLD symptom (longstanding). You may check Old and New if it was previously a problem and was recently worsened. MEMORY Old New (as of _) Forgetting where I leave things (keys, gloves, etc.) Forgetting names Forgetting the faces of people I know Forgetting facts Forgetting events that happened quite recently Frequently forgetting appointments Forgetting where I am or what I am doing Forgetting the order of things (e.g., when cooking, etc.) Relying more and more on notes to remember things Forgetting events that happened long ago (months or years) Other memory problems: _ NEUROSCIENCE INSTITUTE Page 1 of 7 Kirkland, WA 98034

2 Name DOB _ Date _ CONCENTRATION AND AWARENESS Old New Don t feel very alert or aware Highly distractible Problems concentrating Lose my train of thought easily Become easily confused or disorientated Aura (strange feelings, sensations, or smells) Other concentration or awareness problems: PROBLEM SOLVING Old New Difficulty planning ahead Difficulty figuring out how to do new things Difficulty thinking as quickly as needed Difficulty doing things in the right order (sequence problems) Difficulty changing a plan or activity when necessary Difficulty completing activities in a reasonable amount of time Difficulty doing more than one thing at a time multitasking Difficulty switching from one activity to another activity Other problem solving difficulties: SPEECH, LANGUAGE, AND MATH SKILLS Old New Slurred speech Odd or unusual speech sounds Unable to speak Difficulty finding the right word to say Difficulty understanding what others are saying Difficulty writing letters or words Difficulty understanding what I read Difficulty spelling Difficulty with math (checkbook balancing, making change, etc.) Other speech, language, or math problems: NONVERBAL SKILLS Old New Difficulty telling right from left Difficulty doing things I should automatically be able to do (brushing teeth, etc.) Problems drawing or copying Difficulty dressing Problems finding my way around familiar places Parts of my body to not seem as if they belong to me Unaware of things on one side of my body: Right Left Not aware of time Decline in my musical abilities Other nonverbal problems: _ Overall, these symptoms have developed: Slowly Quickly Over the past 6 months, these symptoms have: Stayed about the same Worsened Page 2 of 7

3 Name DOB _ Date _ MOTOR AND COORDINATION Check the side on which it is a problem: Left Right Both Old New Fine motor control problems (using a pencil, key, etc.) Weakness on one side of my body Difficulty holding onto things Tremor or shakiness Muscle tics or strange movements My writing is very small Walking more slowly than most other people Feeling stiff Balance problems Difficulty starting to move Muscles tire quickly Often bumping into things Other motor or coordination problems: SENSORY Check the side on which it is a problem: Left Right Both Old New Loss of feeling or numbness Tingling or strange skin sensations Difficulty telling hot from cold Problems seeing on the side(s) Blurred vision Blank spots in vision Brief periods of blindness See stars or flashes of light Double vision Difficulty scanning Losing hearing Ringing in my ear Difficulty tasting food Difficulty smelling Smelling strange odors Hearing strange sounds Hallucinations: Visual Auditory Other sensory problems: PHYSICAL Old New Headaches Dizziness Nausea or vomiting Blackout spells (fainting) Urinary incontinence Loss of bowel control Excessive tiredness Other physical problems: Page 3 of 7

4 Name DOB _ Date _ BEHAVIOR Rate how severe: Check all that apply to you in the past year: Mild Mod. Severe Sadness or Depression Anxiety or Nervousness Panic Attacks Stress Increased Mood Swings Manic or Euphoric Episodes Become irritable or angry more easily Much more emotional (e.g. cry more easily) Feel as if I just don t care anymore Thoughts of hopelessness or suicide Less inhibited (do or say things I would not do before) Difficulty being spontaneous Sleeping problems (Falling asleep Staying asleep ) Bothered by Nightmares or Flashbacks Memories of an Event Change in eating habits: Eating Less Eating More Change in interest in sex: Decreased Drive Increased Drive Legal Problems Other changes in behavior or personality Have you ever been treated for psychological or psychiatric problems? Yes No Have you ever had a psychiatric hospitalization? Yes No EARLY HISTORY Were you adopted or do not know your early and family medical history? You were born: On time Prematurely Late Don t Know Were there any problems associated with your birth (e.g., oxygen deprivation, unusual birth position, etc.) or the period immediately afterward (e.g., need for oxygen, special equipment used, convulsions, illness, etc.)? Yes No Don t Know Mother s use of drugs/alcohol while pregnant with you? Yes No Don t Know As a CHILD, did you have any of these conditions? (Check all that apply.) Attention Problems Head Injury Speech problems Clumsiness Hearing problems Vision problems Developmental delay Hyperactivity Muscle tightness/weakness Learning disability Psychological Other problems: Check all the conditions that were diagnosed when you were a CHILD. You may specify the age of diagnosis in the blank. Epilepsy or seizures Meningitis Lung (respiratory) disease Fever (104 F+) Encephalitis Fetal Alcohol Syndrome Brain infection Heart problems Immune Problems Cancer Polio Oxygen deprivation Cerebral palsy Diabetes Toxin Exposure Poisoning Tuberculosis Abuse Page 4 of 7

5 Name DOB _ Date _ Other diseases or disabilities Were you exposed to excessive amounts of lead or any other toxin? Yes No As a CHILD, did you have an accident which required a hospital visit? Yes No If yes, describe what happened: Did you ever suffer a serious injury to your head? Yes No If yes, how many? Date(s) of injuries ADULT MEDICAL HISTORY Check all problems or conditions that apply: AIDS, ARC, or HIV Heart disease Parkinson s disease Sleep Apnea Huntington s Brain disease/infection Arteriosclerosis Hypertension Toxin exposure Arthritis Kidney disease Radiation exposure Blood disorder Liver disease Senility (dementia) Polio Respiratory Stroke or TIA Malnutrition Thyroid Cancer or Chemotherapy Diabetes Meningitis Encephalitis/Brain infection Multiple sclerosis Anoxia (no air) Psychiatric problems Any other problems: Do you have epilepsy or had a seizure disorder? Yes No List major hospitalizations/surgeries: a) _ b) _ c) _ Please check all the existed in you or close biological family members (parents, brothers, sisters, grandparents, aunts, uncles): Me Family Member Epilepsy or seizures Learning disability Mental retardation Neurological (brain) disease Alzheimer s disease or senility Huntington s disease Multiple sclerosis Parkinson s disease Other neurological disease Psychiatric Problems: Me Family Member Alcoholism Bipolar illness (manic depression) Depression Personality disorder Schizophrenia Other psychiatric illness NEUROSCIENCE INSTITUTE Page 5 of 7 Kirkland, WA 98034

6 Name DOB _ Date _ MARITAL HISTORY Current marital status: Single Married Partner Separated Divorced Widowed Years married to current spouse: Number of times married: Spouse s name: Spouse s age: Spouse s health: Excellent Good Poor Ages of Children: Who lives with the client currently? EDUCATIONAL HISTORY Highest grade or degree earned: _ Circle the grade range typical for you when in school: A B C D F High school GPA College GPA Were you ever held back to repeat a grade? Yes No and If yes, what grade? And for what reason? Were you ever in any special class(es) or received special serves? Yes No If yes, what grade? Or age? What type of class? OCCUPATIONAL HISTORY Are you currently working? Yes No Current job title (If not currently working, most recent job title): _ Current job responsibilities: _ Prior jobs (start with most recent job) Years employed a) b) c) Vocational Goals: Return to Same Job Find New Employment Return to School Applying for Disability Receiving Disability Income Not Interested in Returning to Work or to School RECREATION Leisure Activities Prior to Injury/Illness _ Current _ MEDICAL TESTING Check medical tests that have been conducted and report any abnormal findings (if known): Check here if normal Abnormal findings Angiography Blood work Brain scan (I, CT) CT scan EEG Lumbar puncture or spinal tap Neurological office exam Physician s office exam NEUROLOGICAL HISTORY Page 6 of 7

7 Name DOB _ Date _ MEDICATIONS (alternatively, you may provide us with a copy of your medication list) Medication Name _ Dosage ALCOHOL I drink alcohol: Never Rarely 1-2 days/wk 3-5 days/wk Daily I used to drink, but have stopped and date stopped: _ Usual number of drinks I have at a time: My last drink was: less than 24 hrs ago hrs ago over 48 hrs Check all that apply: I can drink more than most people my age and size before I get drunk I can sometimes get into trouble (fights, legal difficulty, problems at work, conflicts with family, accidents, etc.) after drinking I sometimes black out after drinking I have had a DWI or DUI charge SUBSTANCE USE Please check all the substances you are no using or have used in the past: Presently using Used in the past Amphetamines (including diet pills) Barbiturates (downers, etc.) Cocaine or crack Hallucinogens (LSD, acid, STP, etc.) Inhalants (glue, nitrous oxide, etc.) Marijuana Opiate narcotics (heroin, morphine, etc.) PCP (or angel dust ) Please list any other drugs: _ Do you consider yourself dependent on alcohol or any above drug or prescription drugs? Yes No Which one(s)? _ Check all that apply: I have gone through alcohol or drug withdrawal I have used IV drugs I have been in substance abuse treatment Page 7 of 7