• Birmingham Neuropsychology

    Voice: (205) 329-7815, fax: 329-7816

    Richard Azrin, Ph.D. Cheryl Millsaps, Ph.D.

  • ADULT PATIENT INFORMATION FORM

  • Instructions: Please complete this form as accurately and completely as you can. Dr. Azrin will discuss your responses with you.

     

    DONT HIT THE BACK BUTTON OR YOU WILL LOSE EVERYTHING.

    Scroll up or down to correct answers.


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  • Evaluation Date:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date form was completed:
     / /
    2 digit month, 2 digit day, 4 digit year :

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like a copy of the report to go to your referral source?
  • Format: (000) 000-0000.
  • Would you like a copy of the report go to to the person or facility you listed above?
  • Gender:

  • Assigned Gender at Birth:
  • Handedness

  • Presenting or Current Problems

  • 0/500

  • Significant Symptoms:

  • Please indicate problems, if any, & when they began for any of the symptoms below: (Leave items blank if they don't appy to you)
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  • Diagnostic Exams:

  • Please describe results of any neurological tests/examinations of your Brain:
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  • Medical History:

  • If you have been diagnosed with any of the following conditions, please indicate whether treatment is controlling it. If not controlled, describe current status:
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  • Have you had any Accidents or Falls leading to injury?
  • Did you have any other Accidents or Falls leading to injury?
  • Did you have any other Accidents or Falls leading to injury?
  • Describe briefly OTHER history of past or present serious illnesses and treatment.
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  • Other Medical History: If there are any other significant medical problems, please describe those: Medical Conditions, Dates, Treatments, and current status:
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  • 0/200
  • Have you ever had Covid

  • Habits

  • Sleep Habits
    Rows
  • Caffeine (please list number of servings of any that you drink)
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  •  :
  • Do you do any formal Exercise?
  • Exercise
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  • Activities of Daily Living:

  • Do you currently hold a driver’s license?
  • Are you currently driving?
  • Please Select ALL of the following activities that you have trouble doing:

  • Have you left items on the stovetop or in the oven and forgotten them more often than usual?
  • Does someone, other than yourself, manage your finances?

  • Have thinking problems made you unable to pay bills, balance checkbook, invest, shop, make change?

  • Current Medications:

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  • If you are completing this on a smart phone, and you would like to take a picture of your medication list, please click Take Photo below:
  • Please list your Prescription Medications (not uploaded above attachments/photos):
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  • Do you take anything for sleep, such as Benadryl, Nyquil, Unisom, Diphenhydramine, or or non-prescription store brand sleeping pills?*

  • Alcohol or Substance Use:

  • Are you currently drinking alcohol?*
  • Have you ever had a drinking problem?
  • Have you been involved in any treatment for Drinking Alcohol (including AA)
  • Have you been involved in any treatment for Using Drugs?
  • Please list any current, recent or past drug use & any treatment for drug or alcohol use:
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  • Smoking/Vaping/Tobacco:

  • Have you ever smoked cigarettes, vaped, or used tobacco:*
  • Are you currently smoking or vaping or using tobacco?

  • Psychological/Psychiatric

  • Please describe below if you have ever had any treatment for psychiatric/psychological difficulties

  • (relationship counseling psychological counseling, medicines for depression or anxiety):
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  • Family Medical History

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  • Education:

  • Did you get a GED?
  • or Did you get a High School Diploma?*
  • Did you ever repeat a grade?
  • Have you ever been enrolled in special education or learning disability classes?

  • Occupation/Vocational History:

  • Are you currently working?*

  • Please list your past jobs, even if not presently working.

  • Please list your job history. Start with your most recent (or current) employment:
    Rows
  • Are you currently receiving any type of disability income?*
  • Are you currently in the process of applying for disability income (SSI or others)?*
  • If you ever served in the military? please complete the following:
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  • Social History:

  • Marital Status

  • Marital History:
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  • Family

  • For the following family members please list their: Name,  Age,  Lives with you (check if yes),  Educational level,  Job, How well you get along, & any Health problems:
    Rows
  • Are you coming to see Dr. Azrin for a possible Attention Deficit Disorder?
  • Are you ready to Submit this form? (please click Yes to continue)*

  • If you don't see the green check box saying "Thank you"

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