NEUROPSYCHOLOGY INTAKE QUESTIONNAIRE

NEUROPSYCHOLOGY INTAKE QUESTIONNAIRE

Although this form is several pages long, very little typing or description is required. Most responses require check-marks only. Please answer all questions as accurately and completely as possible. You will have a chance to discuss answers in detail with the doctor. Your family or friends can help if needed.

1. Name*

First NameLast Name

2. Date of Birth*
Current Age*

3. Gender*

MaleFemaleNonbinaryPrefer not to say

4. Contact information
4. Contact Information
Phone Number*
Please enter a valid phone number.
May we leave a message at this number?*

YesNo
Email Address*
example@example.com
Mailing Address*
What is your preferred contact method?*

PhoneEmail

5. Race*

Caucasian/WhiteHispanicAfrican-American/BlackAsianMiddle EasternOther

6. Handedness (Which hand do you right with the most?)*

RightLeft

7. What is your primary language?*

8. Do you speak/understand any other languages fluently?*

YesNo
What language(s) blanks*

9. Are you your own guardian?*

YesNo

10. Does someone hold Power of Attorney (POA) for you*

YesNo
Names of guardian or POA: *
Guardian/POA Phone Number: *

	Yes	No	Does not apply
Forgetting where I leave things I need on a daily basis (phone, keys, wallet, etc.)
Forgetting the faces of people I know
Forgetting recent events (e.g., forget that you went to a birthday party a few weeks ago)
Forgetting details of conversations that happened quite recently
Repeating self (e.g., same information to same person)
Frequently forgetting appointments
Forgetting the order of things (e.g., steps in familiar recipes, etc.)
Relying more and more on notes/reminders to remember things
Forgetting events that happened long ago (months or years)
Getting lost in familiar places (e.g., at work, at neighborhood store)
Forget to take daily medications at least twice per week
Forget to turn off stove, leave water running, and other such potentially dangerous appliances

	Yes	No	Does not apply
Staying focused on tasks long enough to complete them (e.g., reading a chapter of a book)
Being unable to stick to tasks that are boring, tedious, or time-consuming (happening more often than not)
Easily distracted
Making careless mistakes on assignments/work tasks
Able to follow multi-step commands (e.g., someone asks you to do three things like take out the trash, turn off the light, and lock the door, would you forget to do one of them?)
Lose train of thought easily (e.g., in middle of conversation, change topic or forget what you were saying)
Difficulty sitting still/fidgety
Difficulty following the flow of conversations
Difficulty following the flow of plotlines (e.g., books, movies)
Daydream often/zone out
Feel like my processing speed has slowed down (e.g., thinking as quickly as I used to or need to)
Feel like my processing speed is too fast (e.g., thinking too fast leading to careless mistakes, or missed points)

	Yes	No	Does not apply
Difficulty planning ahead (e.g., planning a vacation, planning errands for the day)
Difficulty doing more than one thing at a time – multitasking
Difficulty thinking as quickly as needed (e.g., processing speed)
Difficulty with organization
Poor time management (e.g., late to appointments, missing deadlines)
Difficulty completing activities/tasks in a reasonable amount of time
Difficulty doing more than one thing at a time – multitasking
Difficulty making complex decisions
Difficulty switching between tasks
Tendency to procrastinate tasks
Verbal impulsivity (e.g., interrupt others while speaking)
Behavioral impulsivity (e.g., unable to wait turn in line, acting without thinking)
Excessive talkativeness
Little or no sense of danger/poor judgement
Difficulty figuring out how to do new things

	Yes	No	Does not apply
Difficulty telling right from left
Difficulty doing things I should automatically be able to do (e.g., brushing teeth)
Problems drawing or copying
Difficulty visually scanning
Miss-reaching for items (e.g., reach for cup and miss it)
Misjudging depth/distance (e.g., miss curb because you thought it was closer)
Not aware of time (e.g., lose track of time often; not sure if it's night or day)

	Left	Right	Both	None
Fine motor control problems (using a pencil, key, etc.)
Weakness on one side of my body
Difficulty holding onto things (e.g., drop items often)
Tremor or shakiness
Balance problems
Difficulty initiating movement
Often bumping into things

	Left	Right	Both	None
Loss of feeling or numbness
Tingling
Difficulty telling hot from cold
Problems seeing on the side(s)
Blurred vision
Light sensitivity
Double vision
Parts of my body seem as if they don’t belong to me
Unaware of things on one side of my body
Losing hearing
Ringing in my ear
Difficulty tasting food
Difficulty smelling
Smelling strange odors
Hearing strange sounds
Hallucinations (Check all that apply): a. Visual b. Auditory c. Tactile

	Yes	No	Does not apply
Headaches
Migraines
Dizziness
Nausea or Vomiting
Blackout spells (fainting)
Urinary incontinence
Loss of bowel control

	MILD Once per week/rarely	MODERATE More days than not	SEVERE Nearly everyday	None
Feeling down, depressed, or hopeless
Little interest or pleasure in doing things
Less interest/pleasure in doing things that you used to enjoy doing
Trouble falling or staying asleep
Sleeping too much
Feeling tired or having little energy
Eating way less than usual
Eating way more than usual
Feeling bad about yourself — or that you are a failure or have let yourself or family down
Trouble concentrating on things, such as reading or watching television
Moving or speaking so slowly that other people could have noticed
Thoughts that you would be better off dead or of hurting yourself in some way
Increased mood swings
Feeling nervous, anxious or on edge
Not being able to stop or control worry
Worry too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Difficulty controlling anger
Afraid something awful might happen
Panic attacks
Upsetting thoughts/memories about a traumatic event that come into your mind against your will
Upsetting dreams about a traumatic event
Acting or feeling as though a traumatic event were happening again
Lacking the desire to sleep, or feel like you don’t need as much sleep to function (e.g., up for at least 2 days with minimal need for sleep)
Episodes of: Talking an excessive amount/”talking a mile a minute”
Episodes of: Having an exaggerated sense of self-worth (e.g., feel like you’re on top of the world and no one can stop you)
Episodes of: Experiencing an excessive amount of racing thoughts/flight of ideas
Episodes of: Taking on excessive workload/projects that you cannot realistically accomplish
Episodes of: Engaging in exciting activities that are potentially dangerous (e.g., shopping spree; substance use binge)
Worrying about having a serious illness, disease, or medical condition
Behaviors you must do excessively or thoughts you must think repeatedly to feel comfortable
Have an unshakable belief in something untrue or that others find hard to believe
Hearing voices, or seeing images that others cannot
Belief that you have special powers that others do not (e.g., reading other people’s minds)
Fear that others are after you or can read your thoughts
Decreased interest in sex
Increased interest in sex

NEUROPSYCHOLOGY INTAKE QUESTIONNAIRE

4. Contact information