Neuropsychological Assessment Clinic
Patient History Form
Patient Initials
First Initial, Last Initial
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Phone Number
-
Area Code
Phone Number
Email Address
Racial Identity
American Indian or Alaskan Native
Asian
Biracial/Multiracial
Black or African American
Latin(x)
Native Hawaiian or Other Pacific Islander
White
Rather Not Say
Other
Gender Identity
Male
Female
Female to Male (FTM)/Transgender Male
Male to Female (MTF)/Transgender Female
Gender Queer
Rather Not Say
Other
Sexual Orientation
Lesbian
Gay
Straight
Bisexual
Don't know
Rather Not Say
Other
Marital Status
Single
Married/Partnered
Divorced/Separated
Widowed
Daughters
Sons
Current Employment Status
Full-time
Part-Time
Per Diem
Unemployed
Retired
Student (Full-Time)
Student (Part-Time)
Job Title
What hand do you write with?
Right
Left
Ambidextrous
Who referred you to us?
Referral Source Name
Referral source contact info:
E.g., phone, address, institution
GENERAL INFORMATION
What are your strengths?
What are you hoping to get from this evaluation?
Describe the problem or reason for evaluation:
When did you first begin to notice these issues?
Within the past 3-6 months
Within the past 12 months
Within the past 1-3 years
Ever since I can remember
Briefly describe how the problem(s) noted above cause difficulty for you (e.g., at work, school, home, with family):
Have you had any problems with (check all that apply):
Thinking
Memory for recent events
Memory for events from a long time ago
Concentration/paying attention
Speech
Saying a word that you did not mean to say
Finding the word you want to use
Understanding what other people say
Reading
Understanding what you read
Sense of direction
Getting lost more than the average person
Ability to walk
Dropping objects/reduced strength in hands
Have you fallen recently?
Yes
No
Do you drive?
Yes
No
Do you ever get lost while driving?
Yes
No
Have you had any car accidents?
Yes
No
Was English your first language?
Yes
No
If English was not your first language, how old were you when you learned to speak English?
What other languages do you speak?
In the past 12 months, what have been your primary stressors?
In the past 12 months, what have been/are your highest priorities?
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DEVELOPMENTAL & EDUCATIONAL HISTORY
Your birth was:
Early
On time
Late
During pregnancy, did your mother use any of the following?
Alcohol
Tobacco
Marijuana
Other drugs
Unknown
Between the ages of 5-12, how often did you exhibit the following:
Never or Rarely
Sometimes
Often
Very Often or Almost Always
Failed to give close attention to details or made careless mistakes with my work
1
2
3
4
Fidgeted with hands or feet/squirmed in seat
5
6
7
8
Had difficulty sustaining my attention in tasks or fun activities
9
10
11
12
Left my seat in situations in which seating was expected
13
14
15
16
Didn't listen when spoke to directly
17
18
19
20
Felt restless
21
22
23
24
Didn't follow through on instructions and failed to finish work
25
26
27
28
Had difficulty engaging in leisure activities or doing fun things quietly
29
30
31
32
Had difficulty organizing tasks and activities
33
34
35
36
Felt "on the go" or "driven by a motor"
37
38
39
40
Avoided, disliked, or was reluctant to engage in work that require sustained mental effort
41
42
43
44
Talked excessively
45
46
47
48
Lost things that were necessary for tasks or activities
49
50
51
52
Blurted out answers before questions had been completed
53
54
55
56
Had difficulty waiting my turn
57
58
59
60
Was forgetful in daily activities
61
62
63
64
Interrupted or intruded on others
65
66
67
68
Check all that apply to your developmental history:
Low birth weight
Birth complications
Mother using alcohol or drugs
Trouble learning to walk, talk or toilet train
Stuttering
Bedwetting
Trouble making friends
Extreme shyness
Recurrent ear infections
Visual problems
Hearing problems
Temper tantrums
Motor clumsiness
What is the highest grade in school/highest degree you have achieved?
8th grade or less
1-3 years of high school
12th grade, high school diploma
GED
Vocational school/other non-college
1-3 years of college
College degree (BA, BS)
Master's degree (e.g., MA, MS)
Professional degree (e.g., PhD, MD)
Have you ever had to repeat a grade?
Yes
No
In school, did you ever have problems with:
Yes
No
Reading
69
70
Spelling
71
72
Writing
73
74
Arithmetic
75
76
Behavior
77
78
Social adjustment
79
80
Attention span
81
82
Following directions
83
84
Have you ever received any of the following services?
Yes
No
Speech language therapy
85
86
Physical therapy
87
88
Occupational therapy
89
90
Counseling/psychotherapy
91
92
Resource room
93
94
Summer school/services
95
96
Tutoring or other accommodations
97
98
If currently enrolled in school, please provide the NAME and CITY, STATE where your school is located:
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MEDICAL & FAMILY HISTORY
Name of your primary care provider (PCP):
PCP Address:
Date of your last physical:
-
Month
-
Day
Year
Date Picker Icon
Have you ever been hospitalized?
Yes
No
If you have ever been exposed to neurotoxins, please describe when, where and for how long you were exposed:
Have you had any of the following tests?
Eye exam
Hearing test
Head electroencephalogram (EEG)
Brain magnetic resonance imaging (MRI or fMRI)
Brain computed tomography (CT or CAT scan)
Have you ever had any of the following (please check all that apply):
Head injury with loss of consciousness
Head injury without loss of consciousness
Cognitive problems after head injury
Head injury required hospitalization
Have you ever been seen by a neurologist?
Yes
No
If yes, please provide the name and phone number of your neurologist:
Please check all that apply to you:
Current
Past
Never or N/A
Cancer
99
100
101
Sleep disorder/disturbance
102
103
104
Trauma/accidents
105
106
107
Diabetes
108
109
110
Heart disease
111
112
113
High blood pressure
114
115
116
Kidney disease
117
118
119
Thyroid disease
120
121
122
Stroke
123
124
125
Seizure
126
127
128
Headaches
129
130
131
Memory loss
132
133
134
Weight loss/gain
135
136
137
Smoking tobacco
138
139
140
Please list any medications you are taking (name, dose, purpose).
Please check all that apply to you:
Current
Past
Never or N/A
Depression
141
142
143
Anxiety
144
145
146
Mania/Bipolar Disorder
147
148
149
Obsessive-compulsive disorder
150
151
152
Psychosis
153
154
155
ECT Treatment
156
157
158
PTSD
159
160
161
Please indicate if you use/have used the following:
Current
Past
Never or N/A
Alcohol
162
163
164
Marijuana
165
166
167
Cocaine
168
169
170
Inhalants
171
172
173
Hallucinogens
174
175
176
Name of your psychologist:
Name of your psychiatrist:
How is your sleep quality?
Excellent
Good
Bad
Terrible
What time do you typically fall asleep?
Do you wake during the night? If so, how often? For how long?
When do you typically wake in the morning?
How many hours of sleep do you get on average?
Do you take naps during the day?
Yes
No
Do you feel well rested when you wake in the morning?
Yes
No
Who raised you?
Siblings? (first name, age, overall health)
Check all that apply if any of your family members have had any of the following (indicate which family member, if applicable):
Yes
No
Mother
Father
Brother
Sister
Maternal Grandparents
Paternal Grandparents
Child
Other
Learning problems
177
178
179
180
181
182
183
184
185
186
Neurological disease
187
188
189
190
191
192
193
194
195
196
Seizures (epilepsy)
197
198
199
200
201
202
203
204
205
206
Intellectual disability
207
208
209
210
211
212
213
214
215
216
Developmental disability/Autism
217
218
219
220
221
222
223
224
225
226
Attentional problems
227
228
229
230
231
232
233
234
235
236
Behavioral problems
237
238
239
240
241
242
243
244
245
246
Depression
247
248
249
250
251
252
253
254
255
256
Anxiety
257
258
259
260
261
262
263
264
265
266
Obsessive-compulsive Disorder
267
268
269
270
271
272
273
274
275
276
PTSD
277
278
279
280
281
282
283
284
285
286
Alcohol/substance abuse
287
288
289
290
291
292
293
294
295
296
Psychosis
297
298
299
300
301
302
303
304
305
306
Bipolar disorder
307
308
309
310
311
312
313
314
315
316
Other psychiatric problems
317
318
319
320
321
322
323
324
325
326
Thyroid disease
327
328
329
330
331
332
333
334
335
336
Kidney disease
337
338
339
340
341
342
343
344
345
346
Heart disease
347
348
349
350
351
352
353
354
355
356
High blood pressure
357
358
359
360
361
362
363
364
365
366
Diabetes
367
368
369
370
371
372
373
374
375
376
Cancer
377
378
379
380
381
382
383
384
385
386
Heart disease
387
388
389
390
391
392
393
394
395
396
Please provide any other important information you think we should know about you:
THANK YOU!
If you have any questions, please call our Administrative Assistant, Mirela, at (617) 702-4273. Once you hit Submit, your completed Patient History Form will be automatically sent to our offices. Thank you!
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