Questionnaire completed by [if different than patient]: blanks
Relationship to patient: blank

How would you prefer to be contacted?    Email     Phone             
DOB/AGE:  * Gender: * Race:    *    
Ethnicity:    *    Language(s) Spoken:    *    
Handedness (hand you write with)    Right     Left *    

Where were you born? blanks * .
... ... If in other country, when did you relocate to the U.S.? blank .
Where were you raised?    blank *  .  Who primarily raised you?    *
How many blood-related siblings do/did you have?     *    
Where are you in birth order (e.g., first, last, 2nd of 5)?    *    
   

When was your last eye exam? blanks *
When was your last hearing exam? blank *

What diagnosis/diagnoses (Please type N/A if not applicable)? blanks *
When did you receive this/these diagnosis/diagnoses (Please type N/A if not applicable)? blank *

When did you retire? blanks *
What field/company did you retire from? blank *

Did/Do you manage or supervise people?    Yes     No *    
Company/organization:    *    
Duration worked for/with this company?    *    

If yes, on what basis and since when? blanks *

Branch and years of service: *
Title/Position:    *    
Deployed? If yes, please provide dates and locations:    *    
Honorable Discharge:    Yes     No *    

Number of times married blanks *
Years married to current spouse blank *

If yes, when? *

Alleged charge(s):    *    

Were you Convicted?     Yes     No *    
Are you currently under any sort of court supervision (e.g., probation)?     Yes     No *    
Are you currently involved in any lawsuits or legal actions?    Yes     No *       
Have you ever been cited for Driving Under the Influence?    Yes     No *