CFNA-NEUROPSYCHOLOGY INTAKE QUESTIONNAIRE

NEUROPSYCHOLOGY INTAKE QUESTIONNAIRE

This form is several pages long but requires minimal typing, with most answers needing only check-marks. Please read each section's instructions carefully and answer as accurately and completely as possible. You will have the opportunity to discuss your responses in detail with Dr. Mangassarian during your evaluation.

Name

First NameLast Name
Email
example@example.com

Rows	Yes, has been occurring over the past month
Frequently misplacing essential items (e.g., phone, keys, wallet)
Forgetting familiar faces
Forgetting familiar names
Forgetting recent events
Forgetting details of recent conversations
Repeating yourself (e.g., telling the same information to the same person in a short time frame)
Frequently missing appointments
Increasing reliance on notes/reminders
Forgetting events from months or years ago (e.g., childhood)
Getting lost in familiar places (e.g., work, neighborhood store)
Forgetting to turn off the stove, water, or other potentially dangerous appliances

Rows	Yes, has been occurring over the past month
Staying focused on tasks long enough to complete them
Difficulty sticking to tasks that are boring, tedious, or time-consuming
Easily distracted
Making careless mistakes on assignments or work tasks
Forgetting steps in multi-step instructions (e.g., asked to take out the trash, turn off the light, and lock the door—forgetting one of them)
Losing train of thought (e.g., mid-conversation, changing topic, or forgetting what you were saying)
Difficulty following conversations
Difficulty following storylines (e.g., books, movies)
Frequent daydreaming or zoning out
Difficulty sitting still or feeling fidgety

Rows	Yes, has been occurring over the past month
Difficulty planning (e.g., organizing a vacation, errands for the day)
Difficulty multitasking
Slowed processing speed (thinking feels slower than usual)
Difficulty staying organized
Poor time management (e.g., frequently late, missing deadlines)
Difficulty completing tasks in a reasonable time
Struggling with complex decisions (e.g., financial or medical choices)
Frequent procrastination
Verbal impulsivity (e.g., interrupting others while speaking)
Behavioral impulsivity (e.g., acting without thinking, trouble waiting your turn)
Poor judgment
Difficulty with problem-solving

Please check all that apply if you have experienced any of the following LANGUAGE difficulties over the past month. IF THE ITEM DOES NOT APPLY TO YOU, SIMPLY LEAVE IT BLANK.

Rows	Yes, has been occurring over the past month
Word-finding difficulties (e.g., using the wrong word, forgetting names of objects)
Difficulty understanding language (e.g., trouble following spoken or written instructions)
Trouble organizing thoughts into sentences (e.g., pausing frequently, losing train of thought mid-sentence)
Difficulty following conversations (e.g., struggling to keep up, needing repetition)

Since first noticing these language difficulties, over time, they seem to be:

Please check all that apply if you have experienced any of the following VISUOSPATIAL difficulties over the past month. IF THE ITEM DOES NOT APPLY TO YOU, SIMPLY LEAVE IT BLANK.

Rows	Yes, has been occurring over the past month
Misjudging depth or distance (e.g., missing a curb because it looked closer)
Mis-reaching for objects (e.g., reaching for a cup and missing it)
Difficulty scanning visually (e.g., trouble finding items in a cluttered space)
Problems with drawing or copying

Since first noticing these visuospatial difficulties, over time, they seem to be:

Rows	Yes, has been occurring over the past month
Fine motor difficulties (e.g., trouble using a pencil, key)
Muscle weakness
Difficulty holding objects (e.g., frequently dropping items)
Tremors or shakiness
Balance problems
Muscle stiffness or rigidity
Blurred vision
Light sensitivity
Double vision
Urinary incontinence or urgency
Bowel incontinence or urgency
Hearing loss
Headaches
Auditory hallucinations (e.g., hearing sounds or voices that aren’t there)
Visual hallucinations (e.g., seeing things that aren’t there)
Hearing loss
Headaches
Migraines
Dizziness
Nausea/Vomiting
Blackout spells (e.g., fainting)

Please check all that apply if you have experienced any of the following SLEEP difficulties over the past month. IF THE ITEM DOES NOT APPLY TO YOU, SIMPLY LEAVE IT BLANK.

Rows	Yes, has been occurring over the past month
Difficulty falling asleep (e.g., takes more than 30 minutes after lying down)
Difficulty staying asleep (e.g., waking up frequently and struggling to fall back asleep)
Diagnosed with sleep apnea but do not use prescribed equipment (e.g., CPAP)
Sleep disturbances (e.g., sleep talking, sleepwalking, acting out dreams)
Need daily naps

Rows	MILD Once per week/rarely	MODERATE More days than not	SEVERE Nearly everyday
Feeling down, depressed, or hopeless
Little interest or pleasure in doing things
Less interest/pleasure in doing things that you used to enjoy doing
Trouble falling or staying asleep
Sleeping too much
Feeling tired or having little energy
Eating way less than usual
Eating way more than usual
Feeling bad about yourself — or that you are a failure or have let yourself or family down
Trouble concentrating on things, such as reading or watching television
Moving or speaking so slowly that other people could have noticed
Thoughts that you would be better off dead or of hurting yourself in some way
Decreased interest in sex
Increased interest in sex
Increased mood swings
Feeling nervous, anxious or on edge
Not being able to stop or control worry
Worry too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Difficulty controlling anger
Afraid something awful might happen
Panic attacks
Upsetting thoughts/memories about a traumatic event that come into your mind against your will
Upsetting dreams about a traumatic event
Acting or feeling as though a traumatic event were happening again
Worrying about having a serious illness, disease, or medical condition
Behaviors you must do excessively or thoughts you must think repeatedly to feel comfortable
Have an unshakable belief in something untrue or that others find hard to believe
Hearing voices, and/or seeing images that others cannot
Belief that you have special powers that others do not (e.g., reading other people’s minds)
Fear that others are after you or can read your thoughts