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

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About You

Personal and contact information

In preparation for your Neuropsychological Evaluation, please complete the following questions as completely and in as much detail as possible. Questions? Call Dr. Kulas at (203) 805-8527.

Patient Information

Patient Name *

Date of Birth

Age

Marital Status

Highest Education Grade

Handedness

Right Left Both

Contact Information

Street Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Phone Cell (alt)

Person Who Assisted Completing This Form

If another person helped you complete this form, please fill in their information below.

Name

Relationship to Patient

Street Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

May this person be contacted for additional information?

Referral Information

Who referred you for this evaluation?

Why were you referred for this assessment?

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

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Medical Information

Current symptoms, providers, and medications

Current Symptoms

Briefly describe what problems or symptoms led you to seek help:

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?

Your symptoms have:

Gotten Worse Gotten Better Stayed the Same

To the best of your knowledge, what is/was the cause 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 Evaluations / Neurological Tests

Please list any previous psychological, neuropsychological, or neurological evaluations.

Date	Doctor	City, State	Reason Evaluated

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Medical History

Hospitalizations and conditions

Medical Hospitalizations

Please list any medical hospitalizations you have experienced.

Date	Hospital Name / Location	Reason Hospitalized

Medical History / Conditions

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

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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Symptoms & Daily Functioning

Check all symptoms that apply to you

Physical Symptoms

Pain Problems — Where?

Incontinence — Type?

Other physical symptoms:

Cognitive Symptoms

Memory Problems Speech / Language Problems Attention / Concentration Difficulty Processing Speed Difficulty Problem Solving Problems

Other cognitive symptoms:

Emotional Symptoms

Other emotional symptoms:

Daily Functioning

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

Basic ADLs (dressing, bathing, feeding) N/A

Complex ADLs (meal planning, trip planning) N/A

Money Management (bills, checkbook) N/A

Medication Management N/A

Driving N/A

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Habits & Substance Use

Alcohol, drugs, and other substances

Alcohol

Do you drink alcohol?

If no, did you drink in the past?

Average current alcohol consumption:

Preferred drink:

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

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

Have you experienced withdrawal symptoms after stopping alcohol?

Have you ever had a blackout?

Is there a history of alcohol abuse in your family?

Have you been involved in alcohol treatment?

Illicit Drugs

Do you currently use illicit/street drugs?

If no, did you use drugs in the past?

Check all that you have used:

Have you ever used IV drugs?

Have you ever overdosed on drugs?

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

Is there a history of drug abuse in your family?

Have you been involved in drug treatment?

Tobacco, Caffeine & Other Substances

Do you smoke or use smokeless tobacco?

Average daily use:

Do you drink caffeinated beverages?

Average daily use:

Do you regularly use over-the-counter medicines (sleeping, diet, pain)?

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

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Mental Health & Personal History

Psychiatric care and early personal background

Mental Health Treatment History

Please list any psychiatric/psychological care you have received.

Dates	Provider Name / Location	Reason Treated

Have you ever been psychiatrically hospitalized?

If yes, please list:

Dates	Hospital Name / Location	Reason Hospitalized

Have you been prescribed psychiatric medications?

If yes, please list:

Dates	Drug Name	Reason Taken

Have you ever undergone Electroconvulsive Therapy (ECT)?

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

Personal / Developmental History

Where were you born?

Birth type:

Single Birth Twin Triplet Other:

Were there any problems or complications with your birth?

Difficulties with early development (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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Background & Compensation

Children, education, employment, and legal matters

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:

Academic weaknesses:

Were you ever held back any grades?

If so, which grades?

Were you ever diagnosed as having a learning disability?

Special assistance received in school:

Behavior problems in school:

Extracurricular activities:

Future education plans:

Employment

Are you currently employed?

If not, when did you last work?

Work history (current job first):

Occupation	From	To	Reason for Leaving

Most significant job:

How illness has affected ability to work:

Future employment plans:

Compensation / Litigation

Do you currently receive Social Security Benefits?

Do you currently receive Worker's Compensation Benefits?

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

Are you currently receiving disability compensation for past illnesses?

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

Current Attorney

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

Name	City, State	Phone	Reason

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Review & Submit

Please confirm your information before submitting

Thank you for completing the Background Questionnaire. Please review your information below, then click Submit to securely send your responses to Dr. Kulas's office. Your information will be kept strictly confidential.

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