NEUROPSYCHOLOGICAL QUESTIONNAIRE

Please fill out this questionnaire completely and thoroughly. Please do not leave any items blank. If there is any part of
this questionnaire that you do not understand, please let your Neuropsychologist know. Thank you for your cooperation.

Full Name:______________________________________________________________ Date: ____________________

Date of Birth: __________________ Age: ________ Best phone number to reach you? _________________________

Right-handed
Are you right-handed or left-handed? _____________

Is English your first language? _____Yes _____ No If no, what is your first language? ________________________

Do you consider yourself fluent in English? _____ Yes _____ No

What is your understanding of the reason for this evaluation?_______________________________________________

__________________________________________________________________________________________________

What questions do you hope to have answered by this evaluation? ___________________________________________

__________________________________________________________________________________________________

Who assisted you with this form? ______________________________________________________________________

Are you involved in any litigation or a lawsuit? _____ Yes _____ No If yes, please explain. _____________________
__________________________________________________________________________________________________

Are you seeking disability? ____________________________________________________________________________

DEVELOPMENTAL HISTORY & EDUCATION

What was your weight at birth? _________
Did your mother have complications during pregnancy? _____ Yes _____ No
Did your mother have complications during labor? _____ Yes _____ No
Did your mother smoke cigarettes or other tobacco products while pregnant with you? _____ Yes _____ No
Did your mother use alcohol while pregnant with you? _____ Yes _____ No
Did your mother use any drugs, including prescription medications, while pregnant with you? _____ Yes _____ No
At what age did you begin walking? ___________
At what age did you begin talking? ____________
At what age did you begin reading? ___________
Did you have speech or language difficulties as a child? _____ Yes _____ No
Were you ever told that you had a learning disability? _____ Yes _____ No
Have you ever been referred for academic, psychological, neuropsychological, or IQ testing? _____ Yes _____ No
If yes, when? ________________________________
Did you ever participate in special education or have a tutor? _____ Yes _____ No
Did you ever repeat or skip a grade? _____ Yes _____ No
Did you participate in school clubs or sports? _____ Yes _____ No
If yes, please list. ____________________________________________________________________________
Did you have any problems with socializing? _____ Yes _____ No
Were you ever suspended or expelled from school? _____ Yes _____ No
If yes, how many times, and for what reasons? ____________________________________________________
Grades in high school (please circle): A B C D F
Did you graduate from high school? _____ Yes _____ No
Year graduated? _____ GPA? _____
If you did not graduate from high school, why not? _______________________________________________________
Colleges, Universities or Major GPA Degree earned
Trade Schools attended & date received

PERSONAL HISTORY
Where were you born? ______________________________________________________________________________
Where were you raised? _____________________________________________________________________________
What was your Father’s profession? ____________________________________________________________________
What was your Mother’s profession? ___________________________________________________________________
How many brothers and sisters do you have (include ages)?__________________________________________________
What is your ethnic/cultural heritage? ___________________________________________________________________
What is your religious/spiritual orientation? ______________________________________________________________
What is your relationship status (circle and indicate how many times and how long)?

Single _____ Married/Partnered _____ Divorced _____ Widowed _____ Separated _____

How many children do you have (include ages and sex)? ____________________________________________________

Who lives at home with you right now? __________________________________________________________________

OCCUPATIONAL HISTORY (If retired, state previous occupations and date of retirement.)
Job Title Employer Dates of Employment

Are you able to work? _____ Yes _____ No

Have you ever served in the military? _____ Yes _____ No
If yes, please answer the following: Length of time served? _______ Highest rank? ___________________
Combat experience? ___________________________________________________
Any disciplinary actions or demotions? _______________________
Type if discharge? _______________________ Rank when discharged? ________________________

OTHER
Do you wear glasses/contacts to correct your vision? _____ Yes _____ No
(check all that apply): O far sighted o near sighted O blurred vision
O double vision o visual blackouts O color blind
o sensitive to light
Do you wear hearing aids, or sound filters? _____ Yes _____ No
(check all that apply): o hard of hearing/ hearing impaired
o buzzing/ringing in the ears
o sensitive to sound
Do you use mobility assistance equipment? _____ Yes _____ No
(check all that apply): cane walker wheelchair
scooter other __________________

Were you ever the victim of abuse (circle all that apply)? _____ Yes _____ No
Physical Sexual Verbal Emotional
Have you ever witnessed domestic violence? _____ Yes _____ No
Have you ever assaulted anyone? _____ Yes _____ No
If yes, please explain: __________________________________________________
Have you ever been arrested? _____ Yes _____ No
If yes, please explain: ___________________________________________________

FAMILY MEDICAL & MENTAL HEALTH HISTORY

What chronic health conditions do (did) your mother and father have? ________________________________________
Do (did) any of your biological relatives have the following? If so, circle and indicate whom.
Epilepsy/seizures ___________________________ Learning disabilities/difficulties ____________________
Neuromuscular disease ______________________ ADHD ________________________________________
Huntington’s or Parkinson’s disease ____________ Depression ____________________________________
Dementia _________________________________ Schizophrenia __________________________________
Anxiety ___________________________________ Bipolar disorder ________________________________

YOUR MEDICAL & MENTAL HEALTH HISTORY

If yes, have you/are you being treated?
Has your doctor ever told you that you have: Yes No Please give details.
Diabetes
High blood pressure
High cholesterol
Heart disease
Stroke
Sleep apnea
Thyroid disturbance
Cirrhosis of the liver
Hepatitis (indicate what type)
HIV/AIDS
Cancer
 Please answer the following questions. Yes No If yes, please give details and
dates.
Have you ever had a serious medical accident or injury?
Have you ever had a bad drug reaction or drug overdose?
Have you ever had an injury to your head (e.g. car or motorcycle accident,
sports injury, bad fall, fights where you got knocked out)?
Have you ever lost consciousness?
If yes, how many times? How long unconscious?
Have you ever been in a head injury rehabilitation program?
Have you ever had brain surgery?
Have you ever had a seizure?
Have you ever seen a neurologist?
If yes, please list all neurologists seen.
Have you ever been diagnosed with a neurological disease (e.g., meningitis,
Parkinson’s disease, multiple sclerosis, etc.)
Have you ever had an MRI, CT scan, SPECT, or PET scan of your head?
Have you ever had radiation or chemotherapy?
Have you ever been on, or are you currently on, disability?

List other CURRENT medical problems, Date of Treatment Please give details including
including serious or chronic medical conditions. diagnosis if the issue is being addressed.

List ALL CURRENT medications you take, including medications for psychological Dose How often?
reasons, vitamins, hormones, and non-prescription drugs.

List PAST hospitalizations and reasons that you were hospitalized. Your age Length of stay
MENTAL HEALTH HISTORY
Have you ever: Yes No Please specify Provider/Place Year
Had counseling or psychotherapy?
Seen a psychiatrist?
Used any medication specifically for
psychological problems?
Been in a drug or alcohol rehabilitation
program?
Had shock treatment?

Please list all hospitalizations (dates and duration of stay) for psychiatric/psychological reasons.

Have you had any of the following? Yes No Please describe

Feeling that people are out to get you
or scheming against you?
Hearing voices others don’t hear?
Feeling or seeing things others do not?
Have ideas that other people think are
odd?
Suicidal thoughts?
Suicide attempts?
Thoughts of harming others?
Attempts to harm others?
Access to weapons?

SUBSTANCE USE
Do you use tobacco or products that contain nicotine? Circle all that apply and indicate how much used per day.
cigarettes__________ cigars_________ pipe_________ chewing tobacco_________
nicotine gum_________ nicotine patch_________ other____________ (Refer / prev given / n:a)
Do you consume products that contain caffeine (e.g., coffee, Pepsi, Coke, Mountain Dew, boost drinks, caffeine tablets?
_____ Yes _____ No
If yes, how much do you consume per day? ____________________________________

Have you ever used or experimented Age Yes No Frequency of use Last time you used
with the following? started this substance
Alcohol
Nicotine/tobacco products
Marijuana
Ecstasy
Psilocybin (mushrooms)
LSD
PCP
Cocaine
Methamphetamine/amphetamines
Heroin
Methadone
Ketamine “special K”
GHB
Prescription medications (narcotics)
Other (please list)
 Please answer the following questions. Yes No Please specify
Have you ever suffered from blackouts from
drugs/drinking too much?
Have you ever been arrested for driving under the
influence?
Have you ever been arrested because of your drinking
or using drugs?
Have you ever lost a job or friends due to your drug
or alcohol use?
Do you have any biological relatives who use (or
used) drugs or alcohol excessively?

How many times in the past year have you used a prescription
medication or street drug for non-medical reasons? ___________

SYMPTOM HISTORY
2 wks
Problems you may be having. (Check ‘yes’ to all that apply, then check to 1 5 10 20 All
the box indicating about how long you have had those problems.) Yes No several yr yrs yrs yrs my
months life
Memory
Recalling things that have happened to you in the past
Recalling things that have recently been told to you
Recalling where you have left items
Recalling how to get to somewhere
Remembering conversations, movies, books
Remembering appointments or medications
Remembering childhood events after the age of 6
Language
Understanding what is said to you
Comprehending what you read
Speaking clearly
Finding the correct names for things or the right words to say
Writing legibly
Spelling correctly
Hand and Body Coordination
Using your right hand
Using your left hand
Using both hands together
Walking
Standing balance
Coordination
Frequent falling
Sensation
Feeling things with your right hand
Feeling things with your left hand
Vision and Perception
Seeing clearly
Driving your car
Following a road map
Making out other people’s faces (familiar people)
Judging distances, height, or depth
 2 wks
Problems you may be having. (Check ‘yes’ to all that apply, then check to 1 5 10 20 All
the box indicating about how long you have had those problems.) Yes No several yr yrs yrs yrs my
months life
Losing your sense of direction or getting lost
Having unusual touch, taste, smell, hearing or vision
Attention/concentration
Becoming tired easily
Chronic fatigue
Having difficulty concentrating
Becoming confused easily
Periods of confusion
Excessive daydreaming
Losing your train of thought
Getting stuck on certain ideas or thoughts
Beginning lots of tasks and not finishing them
Acting first, thinking later (impulsive)
Practical Problems
Managing money
Keeping appointments
Working safely
Handling responsibility
Dealing effectively with the unexpected
Working out problems with your family
Getting along with friends and/or business associates
Organizing or prioritizing
Performing arithmetic calculations or balancing your check book
Medical/neurological
Tension headaches
Migraine headaches
Lightheadedness
Fainting spells
Dizziness/vertigo
Seizures/convulsions
Uncontrollable movements
Tremors
Muscle tics/twitches
Muscle weakness
Muscular paralysis
Numbness/tingling
Excessive or no appetite
Swallowing
Emotional Problems
Tension or anxiety
Worry about health
Panic attacks
Hyperventilation
Irritability
Moodiness
Feeling stress
Unable to relax
 2 wks
Problems you may be having. (Check ‘yes’ to all that apply, then check to 1 5 10 20 All
the box indicating about how long you have had those problems.) Yes No several yr yrs yrs yrs my
months life
Nervous breakdown
Overreact emotionally
Depression or sadness
Anger control
Explosive temper
Change in personality
Recurrent fears
Lack of feelings
Lack of motivation

FUNCTIONAL ACTIVITIES
How do you keep track of your appointments? ___________________________________________________________
How do you get to your appointments? _________________________________________________________________
How do you fix meals? _______________________________________________________________________________
How do you recall important information? _______________________________________________________________
How do you remember to take your medications? ________________________________________________________
How do you handle your finances? _____________________________________________________________________
What household tasks/chores do you perform? ___________________________________________________________
How do you manage/relieve your physical pain? __________________________________________________________
On a 10-point scale, how severe is your pain right now? 0 1 2 3 4 5 6 7 8 9 10
no pain intolerable pain
Where is your pain? ____________________________ Describe pain? ________________________________
Do you have any stress that you’re experiencing now? _____________________________________________________
What leisure time activities do you do (i.e., sports, hobbies, reading, TV, clubs, church, etc.)? ______________
__________________________________________________________ ______________________________________
How many close friends do you have? ____ What kinds of activities do you typically do with them?_________
_________________________________________________________________________________________________
Who are you close to in your family (spouse/partner, parents, siblings, children)?_______________________________
What activities do you typically do with them? ____________________________________________________
How do you cope with stress? ________________________________________________________________________
What are your greatest strengths? ____________________________________________________________________

For office use:

Dep Scrn o
Bgst: Lgl:
Anx Scrn o

Bgn: Abs: Wrtg Smp o

AOQ4 o