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Neuropsychology Preliminary Assessment Form
Neuropsych Preliminary Assessment Form
Neuropsych Preliminary Assessment Form
Client Demographic Details
Name
*
Name
First
First
Last
Last
Date of Birth
*
Age
*
Gender
*
Female
Male
Other
Prefer not to say
Person completing this form
*
Relationship to client
Do you identify as
*
Aboriginal
Torres Strait Islander
Both Aboriginal & Torres Strait Islander
Neither Aboriginal nor Torres Strait Islander
What is your main language of communication?
*
English
Language other than English
If your main language is not English, please state your main language
If you need an interpreter, what language would you prefer?
Who referred the client?
*
Self
Shrink & Co.
Parent
Support Coordinator
Other
If other, please specify who
Social History
Who do you live with
*
Alone
With others
If with others, please specify:
Type of accomodation
*
Own Home
Private Rental
Boarding
Housing Commission
Assisted Living
Nursing Home
Other
If other, please specify:
Main source of income
*
Centrelink
DVA Pension
WorkCover or Other Insurance
Private Income
Nil (Dependant)
Other
If other, please specify:
Diagnosis / Concerns
What is/are the disabilities, conditions and diagnoses of the client
*
What year was the client diagnosed, and by whom?
*
Have you/the client previously completed Neuropsychological testing to support these diagnosis?
Yes
No
If yes, what kind of assessment - please specify details:
History of Presenting Problem
What is the main challenge or difficultly that you face, leading to this assessment?
*
Date the problem/s began (estimate)
*
Is/are the problems:
*
Getting better
Getting worse
Staying the same
Developmental History
Please check any of the following complications experienced during pregnancy of the client (check all that apply)
*
Difficulty in conception
Toxemia
Abnormal weight gain
Abnormal weight loss
Measles
German measles
Jaundice
Flu
Anemia
Emotional problems
Excessive vomiting
Excessive swelling
Vaginal bleeding
High blood pressure
Maternal injury
Hospitalisation during pregnancy
X-rays during pregnancy
Medication during pregnancy
Alcohol during pregnancy
Smoking during pregnancy
Other drugs during pregnancy
Drug use while truing to conceive (mother)
Drug use while trying to conceive (father)
Other
None known
Is the patient adopted?
*
Yes
No
Did you/the client have health concerns as a child? e.g. ear infections
*
Have you/the client had your hearing tested?
*
Yes
No
Have you/the client had your vision tested?
*
Yes
No
If yes to the above questions, what was the outcome?
Educational History
What is the highest level of education obtained?
*
Primary
Secondary
TAFE and above
Did the client/you ever repeat a year level in school?
*
Yes
No
If yes, please specify details
What was the clients performance in school?
*
Above Average
Average
Below Average
Extremely Below Average
Did the client/you ever have difficulty with learning at school? E.g. reading or writing difficulties
*
Yes
No
If yes, please give details:
Did you/the client ever have difficulty socialising with peers?
*
Yes
No
Did you/the client ever experience bullying during school?
*
Yes
No
Current Problems
Check any of the following daily activities that you/the client may have difficulty with
*
Getting dressed
Prepare food
House work
Garden work
Home repairs
Grocery shop
Use telephone
Pay bills
Banking
Take medication
Be home alone
Transportation
Managing appointments
Describe any other activities you/the client may need assistance with:
*
Cognitive Problems
Please check all of the following that currently give you/the client difficulty
*
Mental processes slowed down
Trouble concentrating or easily distracted
Word finding difficulties
Short term memory difficulties
Long term memory difficulties
Losing things
Not able to express yourself using words
Getting lost in familiar places
Excessive daydreaming
Getting lost or difficulty using maps
Disorganised
Acting impulsively (without planning or anticipating consequence)
Have any unusual touch, taste, smell, hearing or vision
Other
If other, please specify
Did these cognitive problems come on gradually or suddenly
*
Gradually
Suddenly
When did you/the client first become aware of them?
*
Psychological, Emotional and Interpersonal Concerns
Please check all of the following that you/the client have recently or currently experience
*
Large or rapid fluctuations in mood
Anxiety
Depressed mood
Manic mood
Tendency to be self-critical or perfectionistic
Thoughts about dying
Attempted suicide
Often irritable or frustrated
Angry or have difficulty controlling temper
Have thoughts most people would consider strange or bizarre
Hallucinations (seeing, hearing, smelling or feeling things that others don't)
Delusions (thoughts you/the client have that others think are unusual)
Difficulty trusting others
Difficulty making friends
Difficulty maintaining back and forth conversations
Difficulty initiating conversations
Obsessive repetition of thoughts that bother you
Compulsive repetition of behaviours that are not really necessary
Frequently interrupts conversations
Serious conflict between family members
Marital problems
Other
If other, please specify
Have you/the client previously experienced trauma? E.g. witnessing domestic violence, physical abuse, motor vehicle accident, childhood neglect, parental separation, etc.)
*
Yes
No
If yes, please provide age and brief details
Have you/the client previously sustained a head injury? E.g. falling out of a tree, concussions, dove into a shallow pool, fell off a bike head first, etc.
*
Yes
No
If yes, provide age and details (please bring any relevant scans and/or reports)
Behaviour
Please check all of the following that you/the client have recently or currently experience
*
Restless/fidgets (e.g. plays with small object in hands/taps feet or hands)
Has difficulty adapting to a change in routine
Unable to see others point of view
Displays socially inappropriate behaviour
Difficulty making decisions
Other
If other, please specify
The following may affect or involve brain functioning. Please check any that you/the client have had:
*
Late to start walking, talking or going to school
Learning disability in school
Attention or behavioural problems in school
Deprived of oxygen (suffocated, nearly drowned, medical complication)
Sleep apnea (stop breathing in your sleep)
High blood pressure
High cholesterol
Heart problems (arrhythmia, heart attack, bypass surgery)
Stroke, or stroke symptoms which went away
Diabetes
Thyroid problems
Seizures
Infection of the brain (encephalitis, meningitis, abscess, etc.)
Hydrocephalus (water on the brain, high intracranial pressure)
Diagnosed with cancer or tumour anywhere in the body
Been a heavy drinker for an extended period of time
Used recreational drugs for an extended period of time
Exposed to toxic chemicals which might damage the nervous system
Exposed to electroconvulsive therapy (ECT)
Other
If other, please specify details
Medication
Please list ALL medications you/the client are currently taking, including dosage and reason
*
Family History
Is there a family history of any mental health or neurodevelopment conditions in your/the clients family members (blood relatives)? E.g. Bipolar, Schizophrenia, Depression, Anxiety disorders, Autism, etc.
*
Yes
No
If yes, please provide details
Is there a history of any physical health conditions in your/the clients family? E.g. Heart disease, Dementia, Seizure, Epilepsy, Diabetes, Cancer, Stoke, etc.
*
Yes
Yes
If yes, please provide details
If you are human, leave this field blank.
Submit
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