Background Questionnaire – Dr. Joseph F. Kulas, Ph.D., ABPP

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BACKGROUND QUESTIONNAIRE

Confidential Information

Joseph F. Kulas, Ph.D., ABPP | Board Certified Clinical Neuropsychologist
The Exchange, Suite 344, 270 Farmington Avenue, Farmington, CT 06032
Phone: (203) 805-8527 | Fax: (888) 494-0373 | [email protected]

In preparation for your Neuropsychological Evaluation, please complete the following questions as completely and in as much detail as possible. You may use the last page or additional sheets as needed. Please bring this completed questionnaire to your evaluation. Questions? Call Dr. Kulas at (203) 805-8527.

Patient Name:

Date Completed:

Address (Street):

Phone H:

City:

State:

Zip:

Phone W:

DOB:

Age:

Cell:

Phone Cell:

Handedness:

R L B

Marital Status:

Education (Highest Grade):

If another person assisted in completing this form, provide information about him/her:

Name:

Relationship to Patient:

Address (Street):

Phone H:

City:

State:

Phone W:

Zip:

Phone Cell:

If necessary, may this person be contacted for additional collateral information?

Y N

Referral Information:Who referred you for this evaluation?

To the best of your knowledge, why were you referred for this assessment?

What would you like to learn about yourself or accomplish from this evaluation?

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Medical Information

Briefly describe what problems or symptoms led you to seek help from your current treatment providers:

List the five problems or symptoms that currently cause you the most difficulty (1 = worst):

1.

2.

3.

4.

5.

Approximately when did these symptoms begin?

Have your symptoms:

Gotten Worse Gotten Better Stayed the Same

To the best of your knowledge, what is/was the cause(s) of these problems?

Current Physicians / Therapists

Please list all current treatment providers.

Name	City, State	Phone	Specialty	How Long?

Current Medications

Please list all medications you are taking (including over-the-counter drugs).

Medication	Dosage	Reason Taking	How Long?

Prior Psychological / Neuropsychological Evaluations or Neurological Tests

Please list any previous evaluations/tests.

Date	Doctor	City, State	Reason Evaluated

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Medical Hospitalizations

Please list any medical hospitalizations you have experienced.

Date	Hospital Name / Location	Reason Hospitalized

Medical History

Please note if you have any of the diseases/conditions below and date diagnosed. Also note if any relatives have these diseases.

Condition	Self	Date Diagnosed	Relative
Diabetes
Heart Disease
High Cholesterol
High Blood Pressure
Cancer (type: )
Chemotherapy / Radiation
Hormonal Problems
Lung / Breathing Problems
Near Drowning
Anemia
HIV / AIDS
Liver Problems
Kidney Problems
Severe Allergic Reactions
High Fever (>104°F)
Electric Shock
Birth / Developmental Problems
Epilepsy
Senility / Dementia
Stroke
TIA
AVM
Traumatic Brain Injury / Concussion
Loss of Consciousness
Lyme Disease
Meningitis
Encephalitis
Toxic Exposure
Brain Cyst / Growth
Other:
Other:

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Please place a check (✓) before each symptom that applies to you:

Physical Symptoms

Other:

Cognitive Symptoms

Memory Problems

Speech / Language Problems

Attention / Concentration Difficulty

Processing Speed Difficulty

Problem Solving Problems

Other:

Emotional Symptoms

Other:

Daily Functioning

Note how much assistance you require for each daily task (1–10 scale).
1 = Fully Independent · 5–6 = Moderate Assistance · 10 = Max Assistance · Check N/A if not applicable.

Task	Rating (1–10)	N/A
Basic ADLs (e.g., dressing, bathing, feeding)		N/A
Complex ADLs (e.g., meal planning, trip planning)		N/A
Money Management (e.g., paying bills, balancing checkbook)		N/A
Medication Management		N/A
Driving		N/A

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Habits — Alcohol

Do you drink alcohol?

Y

N

If no, did you drink in the past?

Y

N

Average current alcohol consumption:

Preferred drink:

Was there a time when your alcohol consumption was heavier than present?

Y

N

Have you had problems due to alcohol use (e.g., injuries, legal, family)?

Y

N

Have you experienced withdrawal symptoms after stopping alcohol?

Y

N

Have you ever had a blackout?

Y

N

Is there a history of alcohol abuse in your family?

Y

N

Have you been involved in alcohol treatment?

Y

N

Habits — Illicit Drugs

Do you use illicit/street drugs?

Y

N

If no, did you use drugs in the past?

Y

N

Check all that you have used and provide details:

Marijuana / Hashish

Amphetamines (e.g., speed)

Cocaine / Crack

Hallucinogens (e.g., LSD)

Inhalants (e.g., nitrous oxide, glue)

Opiates (e.g., heroin, morphine)

Designer Drugs (e.g., Ecstasy, GHB)

Prescription Drugs (e.g., Oxycontin, Xanax)

Others

Have you ever used IV drugs?

Y

N

Have you ever overdosed on drugs?

Y

N

Have you had problems from drug usage (e.g., legal, family conflicts)?

Y

N

Is there a history of drug abuse in your family?

Y

N

Have you been involved in drug treatment?

Y

N

Habits — Tobacco, Caffeine & Other Substances

Do you smoke or use smokeless tobacco?

Y

N

Average daily use:

Do you drink caffeinated beverages?

Y

N

Average daily use:

Do you regularly use over-the-counter medicines (e.g., sleeping, diet, or pain drugs)?

Y

N

Have you ever used performance-enhancing drugs/substances (e.g., steroids)?

Y

N

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Mental Health History

Please list any psychiatric/psychological care you have received.

Dates	Provider Name / Location	Reason Treated

Have you ever been psychiatrically hospitalized?

Y

N

If yes:

Dates	Hospital Name / Location	Reason Hospitalized

Have you been prescribed psychiatric medications?

Y

N

If yes:

Dates	Drug Name	Reason Taken

Have you ever undergone Electroconvulsive Therapy (ECT)?

Y

N

Have any family members received treatment for psychiatric/psychological problems?

Y

N

Personal Information

Where were you born?

Birth type:

Single Birth Twin Triplet Other:

Were there any problems or complications with your birth?

Y

N

Difficulties with early development (e.g., walking, talking, toileting):

Family of Origin

	Age (or age at death)	Education	Primary Job	Health
Father
Mother
Sibling 1
Sibling 2
Sibling 3

Current Marital Status:

Dates of marriage/divorce:

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Children

Name	Gender (M/F)	Age	Health

Religious Denomination:

Recreational interests or hobbies (and how affected by your medical situation):

Education

Highest grade/degree completed:

Year graduated:

Colleges, technical, and/or vocational schools attended (most recent first):

Name	Years Attended	Major / Primary Area of Study

Academic strengths in school:

Academic weaknesses in school:

Were you ever held back any grades?

Y

N

If so, which grades?

Were you ever diagnosed as having a learning disability?

Y

N

Special assistance or help you received in school:

Behavior problems in school:

Extracurricular activities (e.g., sports, clubs):

Future education plans:

Employment

Are you currently employed?

Y

N

If not, when did you last work?

Work history (current job first):

Occupation	From	To	Reason for Leaving

Most significant job:

How current illness has affected ability to work:

Future employment plans:

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Compensation / Litigation

Do you currently receive Social Security Benefits?

Y

N

Do you currently receive Worker's Compensation Benefits?

Y

N

Are you currently receiving disability compensation as a result of your illness?

Y

N

Are you currently receiving disability compensation for past illnesses?

Y

N

Are you currently involved in a lawsuit or other legal action?

Y

N

Current Attorney

Please list the names of any legal counsel currently assisting you.

Name	City, State	Phone	Reason

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