ADULT NEUROPSYCHOLOGICAL QUESTIONNAIRE

Fernando Melendez, Ph.D.

Name Address Occupation Age Phone Date Sex

YES 1. Have there been any changes in your sleep patterns 2. Have you gained or lost weight without 3. Have you had headaches? At what time of day Right side 0 Left side 0 Both 0 Starting in back 0 Front 0 What makes them better What makes them worse 4. Alcohol 5. Tobacco consumption consumption per day per day diet? in the last year?

NO

D 0 D

0 D 0

6. Have you had dizzy spells lately?

7. Have you passed out?

0 0
0 0 0

0 0
0 0 0

8. Have you had changes in the way you walk?

9. Have you had any changes in your vision? 10. Lately, have things dropped out of your hands? 11. Do you sometimes not understand sometimes? the things you read?

0
0 0 0 0

D 0
0 0

12. Do your hands tremble 13. All the time?

14. Has your sense of direction

changed?

15. Have you hit your head lately?

0 0

16. Has your memory changed?

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YES NO 17. Sometimes, when people talk to you, do they seem to mumble?

0 0

0 0 0

18. Do you slur your words sometimes? 19. Sometimes, have you started to say something find it difficult and then forgotten what it was? things

20. Do you sometimes (car, watch)?

21.

to remember the names of common

0 0 0 0 0 0 0
0

0 0 0 0 0 0 0
0

Has anyone in your family had epilepsy?

22. Is there any spot on your head that hurts when touched? 23. Sometimes, does a muscle start jumping temporary or twitching? in one or both eyes?

24. Have you ever experienced

blindness

25. Sometimes

do you see or hear things that others don't?

26. Have you recently lost control of bowels or bladder?

27. Are you right handed? 28. Do you often feel worried or anxious?

29. lately, have you had a feeling that you have been in a place before, even though you know you haven't?

30. Has your handwriting

changed

recently?

0 0
0

0 0
0

31. Sometimes,

do you experience

strong smells when nobody else does? ________

32. Has you sense of smell changed

recently?

33. Have you lately started drinking

more water than you usually do?

0
0 0

0 0 0

34. Has the way you talk changed?

35. Do you lose your balance easily?

YES NO 36. Does any part of your body frequently hurt?

0 0

0 0

37. Have you been in an accident?

38. Who is your physician?

Address 39. When did you last have a complete 40. Do you come in contact 41. List them physical? in your work? with any chemicals

42. What medications

do you take?

43. Have there been any changes in your sexual responsiveness?

0 0

0 0

44. Does any part of your body feel numb?

45. What animals do you come in contact with?

46. Have you ever had syphilis?

0 0

0 0

47. Does either of your eyelids seem to droop a little more than before?

48. Recently,

have you had a thought stop it?

that went on and on in your mind,

and you couldn't

0
disease?

0 0 0 0
0

49. Has anyone in your family had a neurological

0 0 0 0

50. Recently,

have you reached for something

and your hand missed it?

51. Have people's attitudes

towards

you seem to have changed?

52. Can you move your head as well as usual?

53. Your last illness

When 54. Is there often a ringing in your ears?

ADDITIONAL

INFORMATION