Adult Neuro phych

Adult Neuropsychological Testing Form

Patient Information

Patient's Full Name Email Date Age Birth Date Sex

Male Female Other

Education Ethnic/Racial Background Primary Language Secondary Language Hand Used for Writing

Right Left

Current Problem Areas / Areas of Concern

Early History

You were born: On time
Early
Late
Via C-section
Vaginally
Were there any problems associated with your birth (e.g., oxygen deprivation, unusual birth position, underweight, need for oxygen, special equipment used, convulsions, illnesses, etc.)? Yes No If yes, please describe: Check any and all that applied to your mother while she was pregnant with you: Poor nutrition
Accident
Excessive caffeine intake
Smoking
Alcohol consumption
Drug use
Significant stress
Psychological problems
Infections (e.g., rubella, toxoplasmosis)
Gestational diabetes
Hypertension
Premature labor threat
Multiple pregnancy
Placental problems
Rh incompatibility
Exposure to radiation or toxins
Significant bleeding during pregnancy
Any other medical complications (list)

Childhood Conditions

As a child, did you have any of these conditions? (Check all that apply) Attention Problems Learning Disability Other: Were you ever tested for developmental disabilities (e.g., cerebral palsy, specific learning disabilities, autism, ADHD, etc.)? Yes No

Medical History

Please list past and current medical conditions: Have you ever been hospitalized before? Yes No Describe: Have you ever suffered a serious injury to your head? Yes No Describe head injury: Please note all medications taken at present, their dosage, and frequency given. Example: Depakote 100 mg. 2 tablets/ AM, 1.5 tablets/ afternoon, 4 tablets/ evening.

Name	Dosage/Amount	Frequency Given

Family History

Please check all that existed in close biological family members (parents, brothers, sisters, grandparents, aunts, uncles), note who it was, and describe the problem indicated:

Condition	Who	Description
Neurologic (brain) diseases
Alzheimer’s disease or senility
Huntington’s disease
Multiple sclerosis
Parkinson’s disease
Epilepsy or seizures
Other neurologic disease
Psychiatric Illness
Alcoholism
Substance problems
Bipolar illness (manic-depression)
Depression
Anxiety
Personality disorder
Schizophrenia
Other psychiatric illnesses
Learning Disability
Intellectual Disability
Speech or language disorder
Other major disease or disorder
Other (please describe)

Psychosocial History

Current Marital Status: Years Married to Current Spouse: Number of Times Married: Do you have children? Yes No Please list child(ren)'s name(s), age(s), and sex: Who do you currently live with (list): Would you consider the current living situation/environment stressful? Yes No Maybe What is your best attribute/characteristic (e.g., friendly, hard worker)? What is your worst attribute/characteristic (e.g., stubborn, quick-tempered)? Describe any organizations, volunteering, hobbies, reading interests, or other leisure-time activities in which you currently engage: Has you ever been under the care of a psychiatrist, psychologist, or counselor? Yes No If Yes, what were you seen for? Are you currently under the care of:

Legal History

Have you ever been arrested? Yes No If yes, please explain: In the past 5 years, have you incurred any moving traffic violations? (e.g., speeding, DWI, DWAI) Yes No If yes, approximately how many?

Educational History

Number of years of formal education completed: Did you receive a diploma? Yes No If diploma, please indicate degree (e.g., R.S., H.S., B.A., M.A., J.D., M.D., Ph.D.): How would you describe your usual performance as a student? Please provide any additional helpful comments about your academic performance: Were you ever held back a grade? Yes No Were you ever in any special class(es) or received special education services (IEP/504 plan)? Yes No If yes, what grade?

Occupational History

Are you currently employed? Yes No Current Job Title: How long have/had you been on this job? Please give a brief description of your responsibilities: Please list all of the types of jobs you have had in the past: Have you been in the military? Yes No

Substance Use History

I drink alcohol: daily
3-5x/week
weekly
monthly
rarely
never
I used to drink but stopped on (date): I started drinking regularly at age: Preferred type(s) of drinks: Usual number of drinks I have at a time: My last drink was: Check all that apply: I can drink more than most people my age and size before I get drunk
I sometimes get into trouble (fights, difficulty, problems at work, conflicts with family, accidents, etc.) after drinking.
I sometimes blackout after drinking.
I have had a seizure after drinking.
I have missed work or social engagements because of my drinking.
I have been arrested for DUI.
I have experienced the DT’s after I stopped drinking.
I have been in treatment to quit drinking.

If you checked yes to any of the above, please provide details:

Please check all the drugs you are now using or have used in the past:

Substance	Date
Alcohol
Tobacco
Caffeine
Amphetamines (including diet pills)
Barbiturates (downers)
Cocaine or crack
Hallucinogens/LSD
Inhalants (glue, spray cans, etc.)
Marijuana
Opiate narcotics
PCP (angel dust)
Other drugs (drug name) :