Pre-Evaluation Questionnaire Adults

Pre-Neuropsychological Evaluation Questionnaire
If the form is not completed by the patient, please provide the name and relationship to the patient of the individual completing the form.
Reporting Individual's Name

First NameLast Name
Relationship to Patient
Phone Number

Area CodePhone Number
INSTRUCTIONS FOR COMPLETING

Please answer the following questions about your health and history. Although this form is lengthy, it is designed to be very thorough. Completing this information before your appointment will greatly assist the doctor to best use your assessment time with her/him by enabling a more detailed focus.
Demographics
Patient's Name*

First NameMiddle NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Sex*
Patient's Handness*
Patient's Ethnicity*
Patient's Primary Doctor
Doctor's Name
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor's Phone Number

Area CodePhone Number
Doctor's Fax Number

Area CodePhone Number
May we contact your doctor?

YesNo
Referral Information
Who referred you for this evaluation?*
If referred by a specific physician, mental health care provider, or other specialist, please provide his/her name, specialty, and contact information below:
Name of referral*
Specialty
Address of referral

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral's Phone Number*

Area CodePhone Number
Referral's Fax Number

Area CodePhone Number
May we contact the provider who referred you?*

YesNo

	Hired in-home care
Hours a day
Days a week

	Help from family or friend in home
Hours a day
Days a week

Planning for Future Healthcare
Do you have a Durable Power of Attorney (POA)?*

Yes*No
*If yes, who is your POA and relation to you?
Do you have a living will?*

YesNo
Do you have any additional information that you would like the doctor to know about before your visit?
Emergency Contact
Name of Emergency Contact*

First NameLast Name
Relationship*
Emergency Contact Phone Number*

Area CodePhone Number
Should be Empty:

	Do not need help	Need help	Who helps?
Feeding yourself
Getting from bed to a chair
Getting to the toilet
Getting dressed
Bathing
Using the telephone
Taking your medications
Preparing meals
Managing money/financial
Doing laundry
Doing housework
Grocery shopping
Driving
Doing "handyman" tasks
Climbing stairs
Getting to places beyond walking

	Name of medication (e.g., Tylenol)	Strength (Dose) (e.g., 500 mg)	How often per day (e.g., 1 pill 3 times a day)
1
2
3
4
5
6
7
8
9
10

	Yes	No	How often per day?
Cigarettes
E-cigarettes/Vaping
Chewing tobacco

	Name	Age	Regular Contact	Living With
1
2
3
4
5
6

Pre-Neuropsychological Evaluation Questionnaire