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BEHAVIORAL HEALTH SYMPTOM CHECKLIST & TREATMENT CONSENT FORM

BEHAVIORAL HEALTH SYMPTOM CHECKLIST & TREATMENT CONSENT FORM

Patient: 

COGNITIVE QUESTIONAIRE

Since the accident of

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.

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CONSENT

 

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)

Thanks for submitting!

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