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About Us
Overview
Bios & Directory
Clinical Centers
Sleep Study and Treatment
Cognitive and Memory Disorders from Neurodegenerative Diseases
Acquired and Traumatic Brain Injuries
Mind-Body Neuropsychiatric and Mental Health Disorders
Neurodevelopmental Disorders
Careers
Locations
Contact NCBI
Clinical Services
Diagnostics
Neuropsychological Testing
Brain Mapping
ANS Testing
Specialty Tests and Exams
Treatments
Psychotherapy
Neuromodulation
Neurocognitive Rehabilitation
Sleep Disorder Treatment
Telehealth
Research
Overview
NCI Foundation
Clinical Trials at NCBI
Patient Services
Patient Registration
HIPAA Release Authorization
Financial Policy
In-network providers
Out of Network Diagnostic and Treatment Services
Pay My Bill
FAQ
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Patient Intake History
Patient Intake History
General Information
If you are completing this form on behalf of the patient, kindly provide your name and describe your relationship to the patient.
Patient's Legal Name
*
First Name
Last Name
Name of Person Completing Form (LEAVE BLANK if same as Patient Legal Name)
First Name
Last Name
Are you the person's caretaker?
Yes
No
Relationship to Patient
Caretaker Name
*
First Name
Last Name
Caretaker Email
*
example@example.com
Caretaker Mobile Number
*
Is the person listed as the caretaker also the patient's emergency contact?
Yes
No
Please Enter Emergency Contact Name
First Name
Last Name
Please Enter Emergency Contact Number
Please enter a valid phone number.
I. Patient Information
Patient's Preferred Name (if different than legal name)
First Name
Last Name
Patient Email
*
example@example.com
Patient Mobile Number
*
Preferred Pronouns
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Age
*
Gender at Birth
Male
Female
Race
Ethnicity
Handedness
Right-handed
Left-handed
Other
If left-handed: Other left-handed family members?
Yes
No
If yes, specify who in the family is left-handed?
First language learned and spoken fluently?
Second language learned and spoken fluently? (if applicable)
Currently, what is the patient’s primary language?
Receptive Language Abilities
Intact
Mildly-impaired (understands most of what is said to the patient)
Significantly-impaired (comprehends only some of the information)
Expressive Language Abilities
Intact
Mildly-impaired (speaks in phrases but can communicate through language)
Significantly-impaired (difficulty with verbal communication)
Patient Educational Information
Highest Level of Education
Current Grade (for current students only)
Skipped a grade?
Yes
No
If grade(s) were skipped, which?
Repeated a grade?
Yes
No
If grade(s) were repeated, which?
Do you or have you ever received special education services?
Yes
No
If special education services are currently or have been received please explain with time periods received
II. Referral Information
Referral Source
The patient is being evaluated due to difficulties with (check all that apply):
Cognitive Functioning/Developmental Delay
Behavioral Regulation/Inattention/Hyperactivity
Mood Symptoms
Social Functioning/Concern for Autism Spectrum Disorder
Please explain
Additional info:
Is the assessment related to a disability application or ongoing disability claim?
Yes
No
Is the assessment in relation to legal or financial matters (e.g., pending litigation, financial benefit considerations)
Yes
No
Is the patient’s primary insurance Medicaid?
Yes
No
Is the patient seeking solely psychotherapy services, without an interest in neuropsychological assessment?
Yes
No
III. Medications
Current Medications (please specify the date if any medications were added or changed within the past 4 months)
Past Medications
IV. Treatments, Therapies, and Interventions
In the following section, please indicate any past or present treatment or therapy interventions the patient has undergone. It is important to include details such as the dates, duration of the intervention, and response to the treatment. These details should be included in the Notes column.
None
Treatment/Therapy Type
Psychotropics
Current
Past
NA
Notes
(e.g., age started)
Psychotherapy
Current
Past
NA
Notes
(e.g., age started)
School counseling
Current
Past
NA
Notes
(e.g., age started)
Psychiatric hospitalization
Current
Past
NA
Notes
(e.g., age started)
ECT (Electroconvulsive Therapy)
Current
Past
NA
Notes
(e.g., age started)
Speech therapy
Current
Past
NA
Notes
(e.g., age started)
Occupational therapy
Current
Past
NA
Notes
(e.g., age started)
Physical therapy
Current
Past
NA
Notes
(e.g., age started)
Cognitive rehabilitation
Current
Past
NA
Notes
(e.g., age started)
ABA or behavioral therapy
Current
Past
NA
Notes
(e.g., age started)
Social skills group
Current
Past
NA
Notes
(e.g., age started)
Early intervention
Current
Past
NA
Notes
(e.g., age started)
IEP (Individualized Education Program)
Current
Past
NA
Notes
(e.g., age started)
504
Current
Past
NA
Notes
(e.g., age started)
FBA/BIP school behavior plan
Current
Past
NA
Notes
(e.g., age started)
Other school services or accommodations
Current
Past
NA
Notes
(e.g., age started)
Tutoring
Current
Past
NA
Notes
(e.g., age started)
V. Past Neurological, Psychiatric and Medical History
Patient Neurological History Notable for:
None
Unknown
AVMs
CVA ischemic
CVA hemorrhagic
Ischemic microvascular disease
Dementia
Demylenating disorder (atypical)
Gullain-Barre Syndrome
Hemiparesis (left)
Hemiparesis (right)
Hemiplegia (left)
Hemiplegia (right)
Migraines
Meningitis (bacterial)
Meningitis (viral)
Multiple Sclerosis
Muscular Dystrophy
Neoplasms (primary)
Neoplasms (secondary)
New Choice (2)
Neuropathy
Parkinson's Disease
PSP
Seizures
Spinal Cord Compression
Spinal Cord Injury
TIAs
Other
Patient Neurological History Additional information:
Family Neurological History Notable for:
Non-Contributory
Unknown
Early Dementia < 65 y/o
Parkinson’s Disease
Stroke
Multiple Sclerosis
Other
Family Neurological History Additional Information
Patient Psychiatric History Notable for:
None
ADHD
Alcoholism
Anorexia
Anxiety
Autism Spectrum Disorder
Behavior Problems
Bipolar Disorder
Body Dysmorphic Disorder
Bulimia
Depression (episodic)
Disruptive Mood Dysregulation Disorder (DMDD)
Dysthymia
Intellectual Disability
Language Disorder
Learning Disorder - reading
Learning Disorder - writing
Learning Disorder - math
OCD
Oppositional Defiant Disorder (ODD)
Panic Disorder
PTSD
Personality Disorder
Phobias
Psychosis (brief)
Psychosis (unspecified)
Repetitive Behaviors
Sensory Processing Disorder
Schizophrenia
Selective Mutism
Social Pragmatic Difficulties
Somatization Disorder
Suicidal Disorders
Substance Abuse
Other
Is the patient non-verbal (not to be confused with selective mutism)?
Yes
No
Does the patient have down syndrome?
Yes
No
Patient Psychiatric History Additional information
Family Psychiatric History Notable for:
None
ADHD
Alcoholism
Anorexia
Anxiety
Autism Spectrum Disorder
Behavior Problems
Bipolar Disorder
Body Dysmorphic Disorder
Bulimia
Depression (episodic)
Disruptive Mood Dysregulation Disorder (DMDD)
Dysthymia
Intellectual Disability
Language Disorder
Learning Disorder - reading
Learning Disorder - writing
Learning Disorder - math
OCD
Oppositional Defiant Disorder (ODD)
Panic Disorder
PTSD
Personality Disorder
Phobias
Psychosis (brief)
Psychosis (unspecified)
Repetitive Behaviors
Sensory Processing Disorder
Schizophrenia
Selective Mutism
Social Pragmatic Difficulties
Somatization Disorder
Suicidal Disorders
Substance Abuse
Other
Patient Medical History
None
Cancer
No prior cancer history
Breast Carcinoma
Colon Carcinoma
Esophageal Carcinoma
Hodgkin's Disease
Primary Liver Carcinoma
Lung Carcinoma
Melanoma
Ovarian Carcinoma
Pancreatic Carcinoma
Prostate Carcinoma
Other
Cardiac
No prior cardiac history
Angina Pectoris
Esophageal Carcinoma
Arteriosclerotic Heart Disease
Atrial Fibrillation
CAD
Cardiac Arrest
Cardiomyopathy
Hypertension
Orthostatic Hypotension
CHF
Peripheral Vascular Disease
Bradycardia
MI
Respiratory Arrest
Syncope
Tachycardia
Other
Dermatologic
No prior dermatologic history
Acne
Alopecia
Dermatitis
Pressure sores
Cellulitis
Psoriasis
Rosacea
Scabies
Warts
Sunburn
Other
Oral Disorders
No prior oral disorder
Dysphagia
Oropharyngeal based
Esophageal based
Edentulous
Gingivitis
Other
Back
Next
ENT Disorders:
No prior ENT disorder
Earache
External Otitis
Hearing loss
Herpes Zoster Oticus
Labyrinthitis
Laryngitis
Mastoiditis
Meniere’s Disease
Myringitis
Nasal Polyps
Otitis Media
Otosclerosis
Perichondritis
Positional Vertigo
Presbycusis
Rhinitis
Sinusitis
Vocal Cord Paralysis
Vocal Cord Polyps
Vocal Cord Nodules
Tonsillitis
Other
GI Disorders
No prior GI disorder
Colitis
Constipation
Diarrhea
Diverticulosis
Diverticulitis
Dysphagia
Fecal Impaction
Gastritis
GERD
GI Bleeding
Hemorrhoids
Hiatus Hernia
IBS
Pancreatitis acute
Pancreatitis chronic
Esophageal Diverticula
Other
Hepatic and Biliary
No prior hepatic and biliary history
Cholecystitis
Choledocholithiasis
Cholelithiasis
Cirrhosis alcohol
Cirrhosis primary
Fatty Liver
Fibrosis
Hepatitis
Hepatic Granulomas
Vascular lesions
Other
Hematologic
No prior hematologic history
Anemia
Blood transfusion
Hodgkins
Leukemia acute
Leukemia chronic
Leukopenia
Lymphocytopenia
Lymphoma
Platelet dysfunction
Other
Immunodeficiencies
No prior immunodeficiency
Allergies
B cell deficiency
T cell deficiency
Combined B and T cell
No other immunodeficiency
Other
Infectious Disease
No other infectious disease
Other
Metabolic
No prior metabolic disorder
Amyloidosis
Addison's disease
Cushing's syndrome
Electrolyte imbalance
Hyperlipidemia
Hypoglycemia
New Choice
Hypolipidemia
Hyperpituitarism
Hypopituitarism
Hyperthyroidism
Hypothyroidism
IDDM
NIDDM
Porphyria
Renal Disease end stage
Renal Insufficiency
Other
Ophthalmologic
No prior ophthalmologic concerns
Macular degeneration
Glaucoma
Nearsighted
Farsighted
Wears glasses/contacts to correct vision
Blindness Left
Blindness Right
Blindness Bilateral
Vitreous Hemorrhagic
Cataracts
Enucleation Left
Enucleation Right
Enucleation Bilateral
Other
Pulmonary
No prior pulmonary disorder
Asthma
Atelectasis acute
Atelectasis chronic
Bronchiectasis
Bronchitis acute
Bronchitis chronic
COPD
Emphysema
Lung Abscess
Pleural Calcification
Pleural Effusion
Pleural Fibrosis
Pleurisy
Pneumonia
Pneumothorax
Pulmonary Embolism
Respiratory Distress
Respiratory Failure
URI
Other
Rheumatological
No prior rheumatological disorder
Gout
Osteoarthritis (DJD)
Osteomyelitis
Osteoporosis
Paget's Disease
Polymyalgia
Polymyositis
Rheumatoid Arthritis
Scleroderma
SLE
Sjgren's Syndrome
Vasculitis
Systemic Sclerosis
Temporal Arteritis
Wegner Granulomatosis
Other
Status Post-Surgical List:
No post-surgical history
Appendectomy
CABG
Cholecystectomy
Colostomy
Gastrostomy
Hip Replacement
Hysterectomy
Mastectomy
Ileostomy
Intestinal Bypass
Pacemaker Replacement
Aortic Valve Replacement
Other
Have you experienced ongoing symptoms without know medical or psychiatric cause despite multiple visits with a clinician?
Yes
No
If yes, please explain below
Additional Information
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