• 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.


  •
  • Evaluation Date:
     / /
  • Date of Birth:
     / /
  • Date form was completed:
     / /
     :

  • 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:

  • Rows

  • Diagnostic Exams:

  • Rows

  • Medical History:

  • Rows
  • 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?
  • Rows
  • Rows
  • 0/200
  • Have you ever had Covid

  • Habits

  • Rows
  • Rows
  •  :
  • Do you do any formal Exercise?
  • Rows

  • 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:

  • Browse Files
    Cancelof
  • Rows
  • 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?
  • Rows

  • 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

  • Rows

  • Family Medical History

  • Rows

  • 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.

  • Rows
  • Are you currently receiving any type of disability income?*
  • Are you currently in the process of applying for disability income (SSI or others)?*
  • Rows

  • Social History:

  • Marital Status

  • Rows

  • Family

  • 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"

    after you hit Submit, then your form did not submit properly

    If you don't see that Thank you, then please submit again or try saving, or you may have to do the form over again

  • Should be Empty: