NPSInterview



NAME _____________________________

AGE _____________________________

DATE OF BIRTH _____________________________

SEX _____________________________

ADDRESS _____________________________

_____________________________

HOME PHONE _____________________________

WORK PHONE _____________________________

CELL PHONE _____________________________

IF MINOR, NAME OF PARENT OR GUARDIAN

_____________________________

NAME OF REFERRING OR PRIMARY PHYSICIAN __________________________

ADDRESS OF REFERRING OR PRIMARY PHYSICIAN ________________________

_______________________________________________________________

TELEPHONE NUMBER OF REFERRING OR PRIMARY PHYSICIAN_______________

NAME OF INSURANCE COMPANY ___________________________

POLICY NUMBER ________________________________________

POLICY HOLDER ______________________________________

SECONDARY INSURANCE COMPANY _________________________

POLICY NUMBER ________________________________________

Neuropsychological and Psychological Sevices, P.C.

Intake Questionnaire

DATE OF BIRTH:

HISTORY OF PROBLEM:

Brief History of problem (include when began, surrounding circumstances, treatment):

Ongoing symptoms (please check all that apply):

__ difficulty with problem solving

__ problems initiating

__ problems with planning or organizing

__ difficulty switching between tasks

__ difficulty doing more than one thing at a time

__ difficulty finding the right word

__ difficulty understanding what others are saying

__ difficulty writing

__ difficulty making sense of what you are reading

__ difficulty keeping track or recognition time

__ difficulty with reaction time

__ increased distractibility

__ problems concentrating

__ losing my train of thought

__ decreased alterness

__ forgetting where I leave things

__ forgetting events that have happened recently

__ problems learning new information

__ forgetting details from personal history

__ forgetting how to do things

__ tremors or shakiness

__ muscle weakness

__ problems with balance

__ difficulty holding onto things

__ problems with coordination

___ Other symptoms:

Please indicate if you have any difficulties in any of the following areas by checking the function. If so, please describe what those issues are.

___ Self Care

___ Financial Management

___ Shopping

___ Time Management

___ Driving

___ Accessing or Utilizing Community Resources (e.g., church, library, support groups, etc.)

___ Functional Mobility (e.g., getting around the house, getting around outdoors)

___ Leisure and Recreation

___ Prevocational Skills (e.g., typing, writing, reading, etc.)

___ Medical Management (e.g., taking medications, scheduling/keeping doctor appointments, etc.)

___ Socialization

___ Sexual Functioning.

EARLY DEVELOPMENTAL HISTORY

Place of Birth

Language you learned first

If other than English, when did you first begin to learn English

Any known problems with your birth or the surrounding pregnancy.

As a child, did you have any of these conditions or diagnoses? (check all that apply)

___ attention problems ___ head injury ___hearing problems

___ hyperactivity ___ speech problems ___ vision problems

___ developmental delays ___ seizures ___ meningitis

___ encephalitis ___ oxygen deprivation ___ diabetes

___ asthma ___ heart problems ___ high fevers

___ other problems: _________________________________________________

At what age did you first

walk

talk

toilet train

MEDICAL HISTORY

Do you wear glasses? For what reason? __________________________________

Do you require a hearing aid? ___________

Are you color blind? ______________

PLEASE CHECK OFF ANY OF THE FOLLOWING MEDICAL PROBLEMS YOU MAY HAVE EXPERIENCED IN THE PAST OR ARE CURRENTLY EXPERIENCING.

Now Past Now Past

___ ___ Arthritis ___ ___ Meningitis

___ ___ Diabetes ___ ___ Kidney Disease

___ ___ Hypertension ___ ___ Heart Disease

___ ___ Thyroid Disease ___ ___ Liver Disease

___ ___ Parkinson’s Disease ___ ___ Dementia

___ ___ Multiple Sclerosis ___ ___ Stroke or TIA

___ ___ Seizure Disorder

Please list any other medical problems you may have experienced in the past or are currently experiencing

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

PLEASE PROVIDE A LIST OF MEDICATIONS YOU ARE CURRENTLY TAKING

Type Dose When Started Prescribing Physician Problems

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

PSYCHIATRIC HISTORY

Please indicate if you have ever received any of the following diagnoses:

___ Depression ___ Anxiety

___ Bipolar Disorder ___ Panic Disorder

___ Psychosis ___ Schizophrenia

___ Obsessive Compulsive ___ Social Phobia

___ Please list any other psychiatric diagnosis or issue you have had

Please provide a list of any medications you are on for psychiatric reasons

Type Dose When Started Prescribing Physician Problems

_________________________________________________________

_________________________________________________________

_________________________________________________________

Please list all psychiatric hospitalizations you have had.

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

SUBSTANCE ABUSE HISTORY:

Have you had any history of problems with alcohol of other substances?

___ Yes ___ No

Please identify what substances you have had problems with

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

At what age did you start ?

Please indicate what substances (including alcohol) you are currently using

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

Do you consider this use a problem? ___ Yes ___No

FAMILY HISTORY

Please list all members of your family of origin, include any significant medical or psychiatric problems they may have/had.

EDUCATIONAL HISTORY

At what age did you start school?

Did you experience any difficulty starting school? If so what kind of trouble

(e.g., emotional, learning, etc.)?

How many years of education did you attain? Your last degree

Subject/year

If dropped out of school please describe the surrounding circumstances.

Did you every repeat a class or grade?

Any special classes?

Diagnosis or assessments for learning problems/ADD?

VOCATIONAL HISTORY

Please list jobs you have held since finishing school, including any military duty.

Job year started year stopped general duties

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Please describe any unusual circumstances around leaving past jobs

Please indicate your current job

Company

Type of job/Title

Years of experience

Current hours per week

Job description

Current problems on the job

Military History (Please include rank, job duties, branch of service, discharge

date and type)

BEHAVIOR QUESTIONNAIRE

Please indicate if the behavior is a problem for you. If you answer yes, please rate the severity of the problem (1 = mild, 4 = severe)

Anger; difficulty controlling temper Yes No 1 2 3 4

Impatient: upset when needs not easily met Yes No 1 2 3 4

Frequent complaining Yes No 1 2 3 4

Impulsivity; does things without thinking Yes No 1 2 3 4

Argumentative; often disputes topics Yes No 1 2 3 4

Lacks control over behavior; behavior Yes No 1 2 3 4

is inappropriate for social situations

Overly dependent; relies on others unnecessarily Yes No 1 2 3 4

does not do things for self.

Poor decision making; does not Yes No 1 2 3 4

think of consequences

Childish; at times behavior is immature Yes No 1 2 3 4

Poor insight; refuses to admit difficulties Yes No 1 2 3 4

Difficulty in becoming interested in things Yes No 1 2 3 4

Lack of initiative; does not thing for self Yes No 1 2 3 4

Irritable; snappy, grumpy Yes No 1 2 3 4

Sudden/rapid mood change Yes No 1 2 3 4

Anxious; tense; uptight Yes No 1 2 3 4

Depressed; low mood Yes No 1 2 3 4

Irresponsible; can’t always be trusted Yes No 1 2 3 4

Overly sensitive; easily upset Yes No 1 2 3 4

Lacks motivation; lacks interest in doing things Yes No 1 2 3 4

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