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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