NEUROPSYCHOLOGY HISTORY FORM - ADULT
Name: ______Today’s Date: ______Date of Birth:______
Age: ______Marital Status: ______Handedness: R L Both
Race: ______Country of origin ______Is English your first language? Y N
Highest level of education: _____ Most recent/ current occupation ______Currently working? Y N
Have you ever had a neuropsychological/ cognitive evaluation? Y N
PRESENTING PROBLEM
Who referred you to us? ______When is your next appointment with the referring clinician?______
In addition to the referral above, who would you like the report to go to?
Name:______Name: ______
Address:______Address: ______
Phone Number: ______Phone Number: ______
Briefly describe the problems with your thinking/ functioning that bring you here:
______
______
How long have these problems been present?______Have they steadily worsened over time? Y N
Are these problems making it hard for you to:
a. Complete basic daily tasks (For example: dress, groom, bathe) Y N
b. Complete functional daily tasks (For example: Cooking, medication management, finances, driving) Y N
Are you currently taking any medications? If yes, please list (include non-prescription drugs): ______
MEDICAL HISTORY:
Do you have any of the following (Check the appropriate boxes):
☐ High blood pressure ☐ Lyme Disease
☐ High cholesterol☐ Headache
☐ Heart disease/ heart attack☐ Chronic Pain
☐ Stroke/ Mini-stroke☐ Arthritis
☐ Diabetes☐ Vision problems
☐ Kidney disease☐ Bowel/ Bladder Incontinence
☐ Thyroid disease☐ Falls
☐ Liver disease☐ ADHD Diagnosis
☐ Seizures☐ Learning disability diagnosis
☐ Cancer (indicate type) ______☐ MS/ lupus/ Autoimmune related disorder
☐ COPD
For Females only:
☐ Problems related to menstruation (sleep, pain, mood/ thinking changes)
☐ If menopausal/ post-menopausal, problems related to sleep, pain, or thinking/ mood
☐ Hormone replacement therapy
List major surgeries:
______
Have you ever had a head injury? Y NIf yes, please describe: ______
______
Do you have any of the following sleep problems:
☐ Snoring☐ Sleep walking
☐ Wake gasping for air☐ Insomnia
☐ Sleep apnea☐ Restlessness
☐ Wake with sore throat/ headache☐ Nightmares
☐ Wake not feeling rested
Have you ever had any of the following:
☐ MRI/ CT/ PET (brain scan)
☐ MRA
☐ EEG (brain wave)
What were the results of the above? ______
Any recent changes in appetite, energy, fatigue, or pain?Y N If yes, describe: ______
______
MENTAL HEALTH HISTORY:
Have you had any of the following (indicate by circling):
☐ Depression ☐ Visual hallucinations
☐ Anxiety☐ ADHD/ ADD
☐ Panic attack☐ Substance Abuse/ dependence
☐ Eating disorder☐ Trauma
☐ Bipolar disorder☐ ECT(Electro-convulsive therapy)
☐ Hearing voices
Age when did you first receive treatment? _____By whom:______Type of clinician:______
Are you currently in treatment? Y NName of current clinician:______
Current mood: ______
Have you ever been hospitalized for mental health problems? Y N Age:_____Hospital:______
Do you have current thoughts of hurting yourself or ending your own life? Y N
Have you ever had drug or alcohol problems? Y NIf yes, describe: ______
How many alcoholic beverages do you have each week?______
Have you ever drank more than this? ______
Do you smoke tobacco?: Y N If yes, how much?______For how many years?______
How many caffeinated beverages do you drink each day?______
DEVELOPMENTAL, EDUCATIONAL AND OCCUPATIONAL HISTORY:
Have you had any of the following (indicate by circling):
☐ Problems with your mom’s pregnancy with you ☐ Behavior problems
☐ Problems with your birth☐ IEP/ 504 Plan
☐ Speech delays☐ Problems in Reading/ Writing/ Spelling
☐ Motor delays☐ Problems in History
☐Early intervention services☐ Problems in Foreign Language
☐ Difficulties in school requiring tutors/ special classes☐ Problems in Art
☐ Held back in school☐ Problems in Gym/ Coordination
☐ Learning disability☐ Problems in Math
☐ Attention difficulty☐ Problems with handwriting
In school were you (circle one): friendlyshy outgoing withdrawn Angry Hyperactive
If you went to college, where did you go? ______What was your major? ______
If you attended Graduate/professional School, where did you go? ______
What was your field of major? ______Graduated: Y N
Are you currently employed? Y N Retired
If yes, please describe your work ______
If no, what was the nature of the last job you had? ______
If retired, when? ______
Who do you live with?______Nature of your relationship______
Any home life stressors? (For example; significant medical, psychiatric or drug problems within the home, financial stressors) ______
What are your interests or hobbies? ______
Do you exercise regularly? Y N Describe: ______
Legal Questions:
Have you had any of the following (indicate by circling):
☐ Arrests ☐ Divorce/ separation
☐ Legal difficulty☐ DUI/ DWI
☐ Working with an attorney☐ Criminal proceedings
☐ Applying for disability☐ Personal injury
☐ Have applied for disability in the past
☐Receiving disability
If yes to any legal question, describe:______
______
FAMILY HISTORY (Please provide complete information)
Age Age of Death Education Occupation Med/psych/Learning Disorder Hx
Mother ______
Father ______
Brothers______
______
Sisters______
______
Children______
______
Family history (If not described above)-indicate by circling and writing the relation to you above
☐ High blood pressure ☐ Chronic Pain
☐ High cholesterol☐ MS/ lupus/ Autoimmune related disorder
☐ Heart disease/ heart attack☐ ADHD/ Learning disability
☐ Stroke/ Mini-stroke☐ Depression/ Anxiety
☐ Diabetes☐ Auditory or visual hallucinations
☐ Kidney disease☐ Bipolar disorder
☐ Thyroid disease☐ Drug/ Alcohol abuse or dependence
☐ Liver disease
☐ Seizures
☐ Cancer (indicate type) ______
☐ COPD
If there is any other information, which you feel is important for us to know about you, please write it below:______
______
______