ADULT
NEUROPSYCHOLOGICAL HISTORY

Name  						           Date   			
	Address (Street, City, ST, Zip)  								 
	________________________________________________________________
	Phone   (H)  			  (W)				 Email  			
	Birthdate  		_____                      Age  			     Sex 		  
   
                   Where you grew up 							___________

                   Primary language  	______________  Secondary language   		         
	Education  											

           School Attending/Graduated From  							

	Job Title/Firm Name  							___________                
	Writing Hand		   Medication 				    	_____     
           Medical diagnosis  (1)  									
	  	if any	         (2)  									
	Who referred you for this evaluation?   							
	Describe the problems, first major concerns and then minor ones.  			

													
What specific questions would you like answered by this evaluation?
 	(1)  												
	(2)  												
	(3)  												

		THIS FORM HAS BEEN COMPLETED BY:  Patient _____	Other ______
		If not completed by the patient, please provide the following information:

	Name  					    Relationship to patient  			
	Address  											
	Phone (H)  					    (W)  					

SYMPTOM SURVEY

Place a check for each symptom that applies.  Check if this is a NEW symptom (within the past year)  or an OLD symptom (over one year).  Add any helpful comments next the item.

PROBLEM SOLVING
New		Old
				Difficulty figuring out how to do new things
				Difficulty planning ahead
				Difficulty figuring out problems that most other people can do
				Difficulty thinking as quickly as needed
				Difficulty doing things in the right order (sequencing problems)
				Difficulty verbally describing the steps involved in doing something
				Difficulty changing a plan or activity when necessary
				Difficulty completing an activity in a reasonable amount of time
				Difficulty doing more than one thing at a time
				Difficulty switching from one activity to another activity
				Easily frustrated
				Other problem solving difficulties  					

SPEECH, LANGUAGE, AND MATH SKILLS
New		Old
				Difficulty finding the right word to say
				Difficulty understanding what others are saying
				Unable to speak
				Difficulty staying with one idea
				Difficulty writing letters or words (not due to motor problems)
				Slurred speech
				Odd or unusual sounds
				Difficulty with math (e.g., checkbook balancing, making changes, etc)
				Difficulty understanding what I read
				Difficulty spelling
				Other speech, language, or math problems:  			

NONVERBAL SKILLS
New		Old
				Difficulty telling right from left
				Difficulty doing things I should automatically be able to do (brushing teeth, etc)
				Problems drawing or copying
				Difficulty dressing (not due to physical difficulty)
				Problems finding my way around places I’ve been to before
				Difficulty recognizing objects or people
				Parts of my body do not seem as if they belong to me
				Unaware of things on one side of my body:  Right side _____ Left side _____
				Decline in my musical abilities
				Not aware of time (i.e., time of day, season, year)
				Slow reaction time
				Other nonverbal problems:  						

CONCENTRATION AND AWARENESS
New		Old
				Highly distractible
				Lose my train of thought easily
				Problems concentrating
				Become easily confused or disoriented
				Blackout spells (fainting)
				My mind goes blank
				Aura (strange feelings)
				Don’t feel very alert or aware of things
				Other concentration or awareness problems					

MEMORY
New		Old
				Forgets where I leave things (e.g., keys, gloves, etc.)
				Forgetting names
				Forgetting what I should be doing
				Forgetting where I am or where I am going
				Forgetting events that happened quite recently (e.g., my last meal)
				Forgetting events that happened long ago (months or years)
				Need someone to give me a hint so I can remember things
				Relying more and more on notes to remember things
				Forgetting the order of things (e.g., when cooking, etc.)
				Forgetting facts, but I can remember how to do things
				Forgetting how to do things, but I can remember facts
				Forgetting faces of people I know (when they are not present)
				Frequently forgetting appointments
				Other memory problems:  						

MOTOR AND COORDINATION	Check the side this occurs on:
New		Old										Right	  Left	  Both
				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
				My writing is very large
				Walking more slowly than other people
				Feeling stiff
				Balance problems
				Difficulty starting to move
				Jerky muscles
				Muscles tire quickly
				Often bumping into things
				Other motor or coordination problems:  					

SENSORY                                                                                          Check the side this occurs on:
New		Old								Right	  Left	  Both
				Loss of feeling or numbness				  	  	
				Tingling or strange skin sensations			  	  	
				Difficulty telling hot from cold				  	  	
				Problems seeing on one side				  	
				Blurred vision						  	  	
				Blank spots in vision					  	  	
				Brief periods of blindness				  	  	
				See “stars” or flashes of light				  	  	
				Double vision
				Difficulty looking quickly from one object to another object
				Need to squint or move closer to see clearly
				Losing hearing
				Ringing in my ears or hearing strange sounds
				Difficulty tasting food
				Difficulty smelling
				Smelling strange odors      
				Other sensory problems:						

PHYSICAL
New		Old
				Headaches
				Dizziness
				Nausea or vomiting
				Urinary incontinence
				Loss of bowel control
				Excessive tiredness
				Other physical problems:						

BEHAVIOR	Rate how severe:
Check all that apply in the past 6 months	Mild	Moderate	Severe
	      	Sadness or depression						
		Anxiety or nervousness						
		Stress						
		Sleeping problem: (Falling asleep ___ Staying asleep ___)						
		Become angry more easily
		Euphoria (feeling on top of the world)
		Much more emotional (e.g., cry more easily)
		Feel as if I just don’t care anymore
		Doing things automatically (without awareness)
		Less inhibited (do things I would not do before)
		Difficulty being spontaneous
		Change in eating habits: 						
		Change in interest in sex: 						
		Other recent change in behavior or personality:  						

Overall, my symptoms have developed:	____ Slowly	____ Quickly
My symptoms occur:	____ Occasionally	____ Often
Over the past 6 months my symptoms have:	____ Stayed about the same	____ Worsened
In summary, there is:
	_____ Definitely something wrong with me	_____ Possibly something wrong	_____ Nothing wrong

EARLY HISTORY

You were born:	On time ____	Prematurely ____	Late ____

Your weight at birth:  ______ lbs. ______ oz.

Mother’s weight gain during pregnancy:  ______ lbs.

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 ____

	If yes, describe: 		

Check all that applied to your mother while she was pregnant with you:
		Accident
		Alcohol use
		Cigarette smoking
		Drug use (marijuana, speed, cocaine, LSD, etc.)
		Illness (toxemia, diabetes, high blood pressure, infection, Rh incompatibility, etc.)
		Poor nutrition
		Psychological problems
		Other problems: 	

List all the medications (prescribed or over-the-counter) your mother took while pregnant:
_____________________________________________________________________________________
During her pregnancy, did your mother live near a polluted area (e.g., toxic waste dump) or other hazardous are (nuclear plant, industrial area, pesticide sprayed area, etc.)?   Yes  _____     No _____

If yes, describe: ________________________________________________________________________

Rate your developmental progress as it has been reported to you by checking one description for each area:				Early            Average	Late
			Walking	____	____	____
			Language	____	____	____
			Toilet Training	____	____	____
			Overall Development	____	____	____

As a child, did you have any of these conditions?  (Check all that apply)
	____ Attention problems	____ Head injury	____ Clumsiness	
	____ Muscle tightness or weakness	____ Hearing Problems	____Speech problems
	____ Developmental delay	____ Hyperactivity	____ Vision problems
	____ Frequent ear infections	____ Learning disability	
	____ Other problems: _______________________________________________________________

MEDICAL HISTORY

Childhood Medical History

Please check all the following conditions that were diagnosed when you were a child.  Add any helpful details (age at diagnosis, treatment provided, etc.):
____ Allergies		   		____ Epilepsy or seizures		____ Pneumonia	
____ Asthma		   		____ Fevers (104 or higher)		____ Poisoning		
____ Brain infection	   		____ Heart problems			____ Polio		
____ Cancer		   		____ Immune system disease	____ Rheumatic fever	
____ Cerebral palsy	   		____ Kidney problems		____ Scarlet fever		
____ Chicken pox	   		____ Lung (respiratory) disease	____ Tuberculosis		
____ Colds (excessive)	  	____ Measles				____ Venereal disease	
____ Diabetes		   		____ Meningitis			____ Whooping couch
____ Encephalitis			____ Oxygen deprivation
	
Other diseases or disabilities: 										

As a child, were you exposed to excessive amounts of lead (e.g., eating paint chips, living next to high concentrations of automobile exhaust fumes, etc.)?				Yes ____	No ____

If yes, explain:  ________________________________________________________________________

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, explain the circumstances and any problems you had afterwards: ___________________________
__________________________________________________________________________________________________________________________________________________________________________ 
 How would you describe your nutrition as a child and adolescent?
	Excellent ____		Average ____		Poor ____

 List the medications that were regularly given to you as a child:
		Medication				Reason for Medication   
a)  														
b)  														
c)  														
d)  														 

Adult Medical History

Check all that currently apply:

____ AIDS, ARC, or HIV+	   	  ____ Heart Disease			____ Parkinson’s disease	
____ Allergies		                         ____ Huntington’s disease		____ Polio		
____ Arteriosclerosis (artery diseas     ____ Hypertension			____ Psychiatric problems
____ Arthritis		   		  ____ Kidney disease		____ Blood disorder
____ Radiation exposure or therapy	  ____ Liver disease			____ Senility (Dementia)	
____ Brain disease or infection	  ____ Lung (respiratory) disease	____ Stroke or TIA		
____ Cancer or chemotherapy	  ____ Malnutrition			____ Thyroid disease
____ Diabetes		   		  ____ Meningitis			____ Venereal disease
____ Hazardous substance exposure					____ Multiple sclerosis
____ Any other problems:  																									

 List any medications you currently take (over-the-counter or prescription medication), and the dosage.
		Medication					Dosage
a)  													
b)  													
c)  													
d)  													 

Do you have epilepsy or a seizure disorder?			Yes ____	No ____
If yes, check the one you have been diagnosed with:

PARTIAL					GENERALIZED		____  UNCLASSIFIED TYPE
____ Simple partial (Jacksonian)		____ Absence (petit mal)
____ Complex partial (Psychomotor)		____ Myoclonic
____ Partial evolving into generalized	____ Clonic
						____ Tonic
						____ Tonic-clonic (Grand mal)
						____ Atonic

____ I HAVE A SEIZURE DISORDER BUT DON’T KNOW WHICH TYPE.
Please describe it: 												

Describe all of the hospitalizations you have had:
a)  														
b)  														

FAMILY HISTORY

The following questions deal with your biological mother, father, brothers, and sisters

MOTHER

What is your mother’s name?  (Include maiden name)  						
Is she alive    Yes ____	  No ____	If deceased, what was the cause of death? 			
Mother’s occupation: 											
Mother’s level of education 										
Mother’s hobbies 											
Does your mother have a known or suspected learning disability?	Yes ____	No ____
Briefly describe your mother’s health history: 								

FATHER

What is your father’s name?  (Include maiden name)  						
Is he alive    Yes ____	  No ____	If deceased, what was the cause of death? 			
Father’s occupation: 											
Father’s level of education 										
Father’s hobbies 											
Does your father have a known or suspected learning disability?	Yes ____	No ____
Briefly describe your father’s health history: 								

When you were born, what was your mother’s age	____		father’s age 	____
How many brothers and sisters do you have?	____
Where are you in the birth order?			____
Are there any unusual problems (physical, academic, psychological) associated with any of your brothers or sisters?  
If yes, describe: 												
														
Who raised you?
	____  Biological parent(s)			____ Relatives		____ Foster parents
	____  Bilogical parent plus other person	____ Adoptive parents	____ Institutional setting
	____ Others	Who? 											

 What languages were spoken at home when you were a child?
	1)  primary 					2  secondary					

Please check all that existed in close biological family members (parents, brother, sisters, grandparents, aunts, uncles), note who it was, and describe the problem where indicated.
							    	     Who?  
____ Epilepsy or seizures							
____ Learning disability							
____ Left-handedness							
____ Mental Retardation							

Neurologic (brain) disease
	____ Alzheimer’s disease or senility					
	____ Huntingon’s disease						
	____ Multiple sclerosis						
	____ Parkinson’s disease							         Describe
	____ Other neurologic disease		__________________				

Psychiatric illness
	____ Alcoholism							
	____ Bipolar illness (manic-depression)				
	____ Depression							
	____ Personality disorder						
	____ Schizophrenia							
	____ Other psychiatric illness						
            ____ Speech or language disorder					
            ____ Other disorder							
	
PERSONAL HISTORY

MARITAL HISTORY

Current marital status: Married  ____ Single  ____ Divorced  ____  Widowed  ____  Separated ____
Years married to current spouse:  _____
Number of times married:  	   _____
Spouse’s name:  								   Spouse’s Age:  		 
Spouse’s occupation:  											
Spouse’s health:  	Excellent ____	Good ____		Poor ____
Not married, but living with someone:  	Yes   ____		No    ____            His/her age: _____
       His/her health:		Excellent ____	Good ____		Poor ____
       His/her occupation:  											
Children:  _______________________________________________________________________

EDUCATIONAL HISTORY

Highest grade or degree earned 									
How would you describe your usual performance as a student?
       ____ A & B   Please provide any additional helpful comments about your academic performance: ____
       ____ B & C   _______________________________________________________________________
       ____ C & D   _______________________________________________________________________
       ____ D & F   _______________________________________________________________________

 What was your best subject(s)?  			    Weakest subject(s) 			
 Were you ever held back to repeat a grade?		    Yes  ____		No  ____
       If yes, what grade(s)?  				    and reason?  					

Were you ever in any special class(es) or received special services?   Yes  ____	No  ____ 
 
Please summarize the progress (e.g., academic, social, testing) within each of these grade levels 
if possible:

Preschool and Kindergarten											

Grades 1 through 6												

														

Grades 7 through 12												

														

College and Beyond  												

Have you ever in any type of special educational program, and if so, how long?  (If yes, please explain.)
	______ Learning disabilities class			______ Speech & language therapy
	______ Duration of placement			______ Duration of therapy
	______ Behavioral/emotional disorders class	______ Other (please specify)
	______ Duration of placement			______ Duration
			
Have you ever been:  (If yes, please explain.)
	______ Suspended or Expelled from school		______ Retained in grade
			
Did you like school?	Most of the time ______	Sometimes ______	     Almost never _____

Did you:
	Have problems making friends in school?				Yes _____     No _____
	Have problems getting along with teachers?				Yes _____     No _____
	Tend to get sick in the morning before school?			Yes _____     No _____

Describe teacher’s concerns about schoolwork or behavior:

What kind of grades did you receive?
A’s & B’s ______	B’s & C’s ______	  C’s & D’s ______	     D’s & F’s ______

OCCUPATIONAL HISTORY

Current job title:  												
Salary: 	$10,000-29,999  ____   $30,000-$50,000  ____  Over $50, 000 ____
How long have you been on this job?  									
Current job responsibilities:  											
														
										         Time on this job
Prior jobs		a)  											
        (start with	b)  											
        most recent)	c)  											

At any time on a job were you exposed to toxic, hazardous, noxious, or otherwise dangerous or unusual substances (e.g., lead, mercury, radiation, solvents, pesticides, chemicals, etc.)?  Yes / No
If yes, explain:  												

Were you ever fired			 Yes			  No
If yes, explain:	  												

 MILITARY HISTORY

Branch:  													
Discharge rank:  					  Type of discharge:  					
Major military duties:  											
Did you sustain any physical injuries in the military?  			Yes ____	No  ____
Were you ever exposed to any dangerous or unusual substances during your services (e.g., Agent Orange, radiation, etc.)?
If yes, explain:  												

SUBSTANCE ABUSE HISTORY

ALCOHOL

 I started drinking regularly at age:
       less than 10 years old ____	10-15  ____	16-18  ____	19-21  ____	over 21 ____
 I drink alcohol: rarely or never  ____    1-2 days/week  ____	  3-5 days/week  ____  daily ____
       I used to drink but have stopped  ____  Date stopped:  						
Preferred type(s) of drinks:  										
Usual number of drinks I have at a time:  								
My last drink was:  less than 24 hours ago  ____    24-48 hours ago ____   Over 48 hours ago ____
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, legal difficulty, problems at work, conflicts with family,            	     accidents, etc.) after drinking.
        ____ I sometimes blackout after drinking.

DRUGS

Please check all the drugs you are now using or have used in the past:
						     	     Presently using	       Used in Past  
        ____ Amphetamines (inc. diet pills)							
        ____ Barbiturates (downers, etc.)							
        ____ Cocaine or Crack									
        ____ Hallucinogenics (LSD, acid, STP, etc)						
        ____ Inhalants (glue, nitrous oxide, etc.)						
        ____ Marijuana										
        ____ Opiate narcotics (heroin, morphine, etc.)						
        ____ PCP (pr “angel dust”)								

        Please list all other drugs:  																								
Do you consider yourself dependent on any above drug?	Yes ____	No ____
        Which one(s)?  												
Check all that apply:
        ____ I have gone through drug withdrawal
        ____ I have used I.V. drugs
        ____ I have been in drug treatment

MEDICAL TESTING

Check all the medical tests that recently have been done and report any abnormal findings

			 			  	        Check here 	        Abnormal findings
							          if normal
_____ Angiography								    				
_____ Blood work								    				
_____ Brain scan								    				
_____ CT scan								    				
_____ EEG									    				
_____ Lumbar puncture or spinal tap					    				
_____ Magnetic Resonance Imaging (MRI)					    				
_____ Neurological office exam						    				
_____ PET scan								    				
_____ Physicians office exam						    				
_____ Skull X-ray								    				
_____ Ultrasound						______	    				
_____ Other testing:                       						    				

Identify the physician who is most familiar with your recent problems:
Name of physician:  												
Address:  													
	     													
Phone:      													
Date of your last medical check-up:  									
Findings of the last check-up:  										

Have you had a prior psychological or neuropsychological evaluation?
If yes, complete this information:
Name of psychologist:  											
Address:  													     
														
Phone:  													
Date of and reason for this evaluation:  									
Findings of the evaluation: