Neuropsychological Testing Appointment
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1 Neuropsychological Testing Appointment Steven A. Rogers, PhD Kathleen D. Tingus, PhD 1701 Solar Drive, Suite 140 Oxnard, CA When will it be? Date: Time: Examiner: What will I have to do? Each appointment will last approximately 3 hours (with breaks) and include: 1. A Clinical Interview (approximately minutes) During this interview, you will be discussing your medical history and any cognitive or physical concerns that you may have. Please bring someone with you to this interview (e.g., caregiver, family member) as it is helpful to have someone else to provide additional information. This person is free to leave following the interview or they can sit in the waiting room while you complete the testing portion. 2. Cognitive Testing (approximately hours) Testing will involve basic paper-and-pencil tasks, as well as motor tests, that are designed to assess skills in memory, language, attention and concentration, and higher-order executive abilities. How will this benefit me? The results of testing serve as an important diagnostic tool for physicians. For example, it may be used to: Aide in differential diagnosis Identify cognitive strengths and/or weaknesses Monitor disease progression Monitor potential medication side-effects Establish a baseline for continued monitoring of potential cognitive changes What should I bring? Be sure to complete and bring the attached questionnaire, any snacks or drinks you may want during the breaks, and a sweater or jacket. Cancelled or Missed Testing Appointment Policy Please call us at (805) as soon as possible if you are unable to attend your appointment. If it is necessary to cancel or reschedule your appointment, please call at least 48 hours in advance. Your early cancellation is needed to give us sufficient time to make this appointment available to someone else. If an appointment is not cancelled at least 48 hours in advance, you will be charged a $25 fee, which will not be covered by your insurance company. We require that this fee be paid prior to any future appointments. Thank you for your cooperation and understanding. We look forward to working with you!
2 Steven A. Rogers, PhD Kathleen D. Tingus, PhD 1701 Solar Drive, Suite 140 Oxnard, CA NEUROPSYCHOLOGICAL QUESTIONNAIRE IDENTIFYING INFORMATION: Name: Date of Birth: Handedness: R / L / A Native language: Cultural/ethnic background: DEVELOPMENTAL HISTORY 1. Where were you born? 2. To the extent you are aware, please list any problems associated with your birth or the immediate time period after birth (e.g., oxygen deprivation): 3. Please check all that applied to your mother while she was pregnant with you: Drug or Alcohol use Environmental toxin exposure Illness Cigarette smoking Malnutrition Accidents 4. Please indicate any learning disabilities, developmental problems, etc. Psychological Problems Other: Delay in walking Delay in talking EDUCATIONAL HISTORY Dyslexia ADHD Other: 1. What is the highest grade that you completed in school? 2. Please list any degrees received: 3. As a student, were your grades mostly A s B s C s D s or F s (check all that apply)? WORK HISTORY: 1. Are you currently still working? Yes No. If no: a. What year did you retire? Did your illness force you to stop working? Yes No 2. Please list current and prior jobs (starting with the most recent): b. c. d. e. f. 4. Were you ever in the military? Yes No. If yes, please indicate: a. Length of service: Rank/branch: b. Position(s) held: 1
3 5. What community, volunteer, or other activities are you currently involved in? 6. What are your current recreational interests (e.g., exercising, crossword puzzles)? CURRENT LIVING SITUATION 1. Please indicate your current marital status: Married: Years married: Number of prior marriages: Divorced Single Widowed Separated 2. Please specify the number of children, grandchildren, and greatgrandchildren you have, if applicable. 3. Is anyone your conservator or legal guardian? If yes, who? 4. What help or supervision do you need from others (check all that apply)? Completing finances Remembering to take medications Operating appliances (e.g., oven) Remembering to turn off the stove or water Dressing Showering Operating electronics (e.g., TV remote) Other: 4. Do you currently drive? Yes No. If no, when did you stop? Please describe reason for stopping: MEDICAL HISTORY 1. Please list any surgeries and year performed: a. Year: b. Year: c. Year: d. Year: e. Year: f. Year: 2. Please indicate current and past medical conditions or illnesses (check all that apply): High cholesterol High blood pressure Heart disease Diabetes (Type I or Type II ) Thyroid problems (underactive Sleep apnea Seizure disorder (Specify type/frequency): Other(s): 3. Have you ever experienced a stroke, head injury, or any other serious or neurological injury not mentioned above? Yes No. If yes, please describe: SUBSTANCE USE HISTORY 1. Do you have any history of alcohol use? Yes No. If yes, please specify: a. Age (or year) started / Age (or year) stopped (if applicable) b. Type and amount consumed per day: 2
4 c. Please describe any history of heavy or frequent alcohol use? 2. Do you have any history of smoking? Yes No. If yes, please specify: a. Age (or year) started / Age (or year) stopped (if applicable) b. Type/amount consumed per day: 3. Do you have any history of illicit substance use (e.g., cocaine, marijuana, etc.)? Yes No If yes, specify type and frequency: PSYCHIATRIC HISTORY 1. Please indicate any history of mental health problems or diagnoses (check all that apply)? Depression Anxiety Bipolar Disorder Other(s): 2. Please describe any mental health treatment (psychotherapy, medication, etc.) received (current and past): 3. Have you ever experienced any hallucinations? Yes No. If yes, please: a. Describe them: b. Indicate when your first hallucination occurred? COGNITIVE CHANGES 1. Please describe any cognitive problems you are having now: a. Difficulty with problem solving or reasoning (e.g., puzzles): b. Problems with speed of thinking: c. Problems with attention or concentration: d. Problems with memory: e. Problems with speaking or reading: f. Problems with spatial abilities (e.g., getting lost driving): 2. When did you first start noticing any of the above cognitive changes? 3. Please indicate progression of change: Gradual Rapid Sudden Stepwise 3
5 FAMILY HISTORY 1. Please indicate any family history of psychiatric, substance abuse, or neurological problems (check all that apply): Dementia (Type: ) Parkinson s disease Strokes Diabetes Depression Alcohol abuse 2. Please list any other family history of medical conditions, neurodegenerative disorders, or psychological problems: 3. If applicable: a. At what age did your mother pass away? b. At what age did your father pass away? PHYSICAL CHANGES 1. Have you experienced any of the following physical changes (check all that apply)? Tremor (Which hand? R, L, or Both) Balance problems Small handwriting Difficulty swallowing Increase in saliva Shuffling gait Freezing gait Magnetic gait (feeling like your feet are stuck to the ground by magnets) Decreased sense of smell Decreased muscle strength Decreased coordination Softened speech Slurring and/or stuttering Visual complications Other(s): If yes to any of the above items: a. Which symptom occurred first, and when did it start? b. Are you taking medication(s) for your symptom(s) (e.g., levodopa)? Yes No. If yes: i. Describe any improvement in your symptom(s) since beginning the medication(s): 2. Have you ever been diagnosed with Parkinson s disease? Yes No. If yes: a. When were you diagnosed? 3. Please describe any other current concerns or difficulties not mentioned above: 4
6 This section is to be filled out by a caregiver, friend, or family member. Name: Relationship to patient: 1. Does the patient demonstrate: a. Difficulty with problem solving or reasoning (e.g., puzzles)? If so, please describe: b. Problems with speed of thinking? If so, please describe: c. Problems with attention or concentration? If so, please describe: d. Problems with memory? If so, please describe: e. Problems with speaking or reading? If so, please describe: f. Problems with spatial abilities (e.g., getting lost)? If so, please describe: 2. When did you first notice any of the above cognitive changes? 3. Please indicate progression of change: Gradual Rapid Sudden Stepwise 4. Has the patient ever harbored any thoughts or beliefs that you consider unusual (e.g., believing others are stealing from them or trying to break into their home)? Yes No. If yes, please describe: 5. Has the patient ever exhibited any hallucinations, personality changes, or other unusual behaviors not previously mentioned? If yes, please describe: 6. Does the patient demonstrate any difficulty: Completing his/her finances Remembering to take medications Operating appliances (e.g., oven) Operating electronics (e.g., TV remote) Remembering to turn off the stove or water Cooking Cleaning Other: 6. Please describe any other concerns or difficulties demonstrated by the patient: 5
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