Neuropsychology Preliminary Assessment Form

Neuropsych Preliminary Assessment Form

Neuropsych Preliminary Assessment Form

Client Demographic Details

Name
Name
First
Last
Gender
Do you identify as
What is your main language of communication?
Who referred the client?

Social History

Who do you live with
Type of accomodation
Main source of income

Diagnosis / Concerns

Have you/the client previously completed Neuropsychological testing to support these diagnosis?

History of Presenting Problem

Is/are the problems:

Developmental History

Please check any of the following complications experienced during pregnancy of the client (check all that apply)
Is the patient adopted?
Have you/the client had your hearing tested?
Have you/the client had your vision tested?

Educational History

What is the highest level of education obtained?
Did the client/you ever repeat a year level in school?
What was the clients performance in school?
Did the client/you ever have difficulty with learning at school? E.g. reading or writing difficulties
Did you/the client ever have difficulty socialising with peers?
Did you/the client ever experience bullying during school?

Current Problems

Check any of the following daily activities that you/the client may have difficulty with

Cognitive Problems

Please check all of the following that currently give you/the client difficulty
Did these cognitive problems come on gradually or suddenly

Psychological, Emotional and Interpersonal Concerns

Please check all of the following that you/the client have recently or currently experience
Have you/the client previously experienced trauma? E.g. witnessing domestic violence, physical abuse, motor vehicle accident, childhood neglect, parental separation, etc.)
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.

Behaviour

Please check all of the following that you/the client have recently or currently experience
The following may affect or involve brain functioning. Please check any that you/the client have had:

Medication

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.
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.