BEHAVIORAL HEALTH SYMPTOM CHECKLIST & TREATMENT CONSENT FORM
1. I am more forgetful and my memory has gotten worse
2. I feel more confused and forget where I have to go or what I have to do
3. I feel I can’t make decisions or solve problems like I used to
4. I feel my thoughts are all mixed up and I can't think straight.
5. I am having problems with directions and often get lost.
6. I can't speak or say what I want; the words don't come out the way I want
7. I can't concentrate or pay attention to things like I used to.
8. I am having many headaches and/or feel dizzy and/or have blurred vision and/or problems with balance.
9. I hit my head in the accident.
BASED ON THE SYMPTOMS I HAVE CHECKED OFF, I AM VOLUNTARILY REQUESTING TO BE EVALUATED REGARDING TREATMENT FOR MY COMPLAINTS.
NYS FORM NF-AOB (Rev 1/2004)