Adult Background History | Neuropsychology Testing & Cognitive Assessment

Thank you for choosing the Cognitive Assessment Group. Please fill out the background history questionnaire prior to your appointment with us. If you prefer, download the form in PDF format here. We look forward to working with you!

1 Personal Information

2 Medical History

3 Psychiatric History

4 Substance Use History

5 Personal History

6 Current Complaints

7 Additional Comments

8 Review Submission

Name*
First Last
Sex*
- Male
- Female
Contact*
Select all means of contacting you
- Home Phone
- Work Phone
- Cell Phone
Home Phone*
Work Phone*
Cell Phone*
Email*
SSN*
Enter just numbers and no dashes
Employment Status*
- Employee
- Self Employed
- Unemployed
Employer Name*
Employer Address*
Date of Birth*
Age*
Ethnicity*
Referred By
Referral Question or Presenting Problem*
Primary Physician
Other Specialist(s)
Include name and specialty

Save and Continue Later

Hospitalizations, Surgeries, Accidents
Check all that apply
- Hospitalizations
- Surgeries
- Accidents

Hospitalizations

Click the plus button to add more entries. Click the minus button to remove an entry.

When Occurred	Age	Length of Stay

Surgeries

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When Occurred	Age	Length of Stay

Accidents

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When Occurred	Age	Length of Stay

Serious Illnesses
Current Medical Problems
Family Medical Problems
Head Injury or Concussion
Seizures
Other Neurological Disorders
Family History Neurological Illness

Current Medications