BEHAVIORAL HEALTH SYMPTOM CHECKLIST & TREATMENT CONSENT FORM

Patient:

First Name

Last Name

Date

COGNITIVE QUESTIONAIRE

Since the accident of

Accident Date

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.

Select an option

Yes

Select an option

Yes

Select an option

Yes

Select an option

Yes

Select an option

Yes

Select an option

Yes

Select an option

Yes

Select an option

Yes

Select an option

Yes

CONSENT

BASED ON THE SYMPTOMS I HAVE CHECKED OFF, I AM VOLUNTARILY REQUESTING TO BE EVALUATED REGARDING TREATMENT FOR MY COMPLAINTS.

Signature of Patient

NYS FORM NF-AOB (Rev 1/2004)

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