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Questionnaire for New Patient Request
Questionnaire for New Patient Request
Instructions: This form needs to be completed in its entirety prior to scheduling an appointment for neuropsychological assessment. In addition, please include relevant medical records and information (e.g., neuroimaging results, previous neuropsychological/psychological evaluation reports, historical and current diagnoses, current medications, chart notes).
24Questions
New Patient Request
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    • Albania
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    How log have you had symptoms? *
    On-going, off-and-on? *

    Referred by:    *    

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    More than one? How many? *       
    When/Age?    *    
    Hospitalized/ER?    *    
    Loss of Consciousness? For how long?    *    
    Needed Rehabilitation?    *    

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    What diagnoses? *
    How currently treated?    *    

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    When diagnosed?    *    
    Special education?    *    
    Repeat grade/Held back?    *    
    What's your highest level of education?    *    

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    When diagnosed?    *    
    Treatment history:    *    
    Currently being treated?    *    
    Evaluated in Childhood or Early Childhood:    *    
    Neurological issues; migrates, medical:    *    

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    What diagnoses?    *    
    When diagnosed?    *    
    Ever need inpatient psychiatric hospitalization?        *    
    Currently treated with medications?         *    
    ...... If Yes, By who?       For How Long?      
    In counseling? With who?     *    

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    When?    *    
    Did you hospitalized?        *    Where you hospitalized?       

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    Ever been awake for a few days because you didn’t feel the need to sleep?       *       
    Had excess energy?        *       
    On the go with a race of thoughts?         *    

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    What School? *
    What are you going to school for (goal/major):    *    

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    Have you seen any other Doctors, Specialists, Counselors, Psychiatrists: *
    Past or present diagnosis: *
    Are you taking any medications?     *    
    Past or present learning disabilities:    *    
    Are your Physicals with a Primary Care Physician current?     *    
    Have you had any recent blood work:    *    
    Does blood work show any issues? Such as vitamin deficiency, thyroid functions:    *    

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