• 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.
  • 4. Contact information

  • What language(s) *

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

  • Instructions: For the next set questions, please indicate if you have been experiencing any of the following OVER THE PAST MONTH.

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  • Instructions: For the next set questions, please indicate if you have been experiencing any of the following OVER THE PAST MONTH.

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  • Instructions: For the next set questions, please indicate if you have been experiencing any of the following OVER THE PAST MONTH.

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  • Instructions: For the next set questions, please indicate if you have been experiencing any of the following OVER THE PAST MONTH.

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  • Instructions: For the next set questions, please indicate if you have been experiencing any of the following OVER THE PAST MONTH.

    Instead of YES/NO, the answer will allow you to choose Left (for left side of body), Right (for right side of body), or both (for both sides of body) to specify what side of the body the issue effects. You can leave an item blank if it does not pertain to you.

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  • Instructions: For the next set questions, please indicate if you have been experiencing any of the following OVER THE PAST MONTH.

    Instead of YES/NO, the answer will allow you to choose Left (for left side of body), Right (for right side of body), or both (for both sides of body) to specify what side of the body the issue effects. You can leave an item blank if it does not pertain to you.

    Check the side on which it is a problem

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  • Instructions: For the next set questions, please indicate if you have been experiencing any of the following OVER THE PAST MONTH.

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  • Instructions: Please check any activities you CANNOT do on your own or require some  assistance with:

  • INSTRUCTIONS: For the following section, please indicate if your CURRENT/RECENT (within the past year) emotional/behavioral symptoms are mild, moderate, or severe. If the  item does not apply, do not mark any column.

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  • Should be Empty: