NYU School of Medicine

Please send completed application to:

NYU School of Medicine

Center for Brain Health

Dept. of Psychiatry, MHL 400

550 First Avenue

New York, NY 10016

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(All information supplied in this questionnaire is strictly confidential)

DATE: _____/_____/_____

NAME: ______

FirstInitialLast

ADDRESS: ______

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HOME: ( ) ______- ______WORK: ( ) ______- ______

E-MAIL: ______

SS#: ______REFERRED BY: ______

APPLICANT INFORMATION:

AGE: ______SEX: ______HEIGHT: ______WEIGHT: ______

DATE OF BIRTH: ______/______/______BIRTHPLACE: ______

PRIMARY LANGUAGE SPOKEN: ______

SECOND LANGUAGE(S): ______

MARITAL STATUS (Check one): □ Single (never married) □ Married

□ Widowed □ Divorced □ Separated

If married, name of spouse: ______

RACE: □ African American □ Caucasian □ Asian □ Hispanic □ Other ______

RELIGION: ______

CURRENTLY EMPLOYED: □ Yes □ No□ Retired

If retired, # of years since retiring: ______

OCCUPATION (or type of work): ______

YEARS OF EDUCATION: ______HIGHEST DEGREE OBTAINED: ______

PRIMARY CONTACT PERSON:

NAME: ______

RELATIONSHIP TO APPLICANT: ______

ADDRESS: ______

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HOME: ( ) ______- ______WORK: ( ) ______- ______

E-MAIL: ______

RELATIVE OR FRIEND:(in addition to PRIMARY CONTACT PERSON above)

NAME: ______

RELATIONSHIP TO APPLICANT: ______

ADDRESS: ______

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HOME: ( ) ______- ______WORK: ( ) ______- ______

E-MAIL: ______

PRINCIPAL FAMILY PHYSICIAN

NAME: ______

OFFICE PHONE: ( ) ______- ______

ADDRESS: ______

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CHECK ONLY ONE RELEVANT COLUMN FOR EACH SYMPTOM

(from not at all present to severe):

SYMPTOMNOT AT ALLMILDMODERATESEVERE

ANXIETY______

TENSION______

AGITATION______

DEPRESSION______

CONFUSION______

DISORIENTATION______

POOR MEMORY______

POOR CONCENTRATION______

REDUCED ACTIVITIES______

POOR MOTIVATION______

FATIGUE______

INSOMNIA______

DISTURBED SLEEP______

POOR APPETITE______

SEXUAL PROBLEMS______

INCONTINENCE______

PANIC REACTIONS______

IRRATIONAL THOUGHTS______

DELUSIONS______

HALLUCINATIONS______

OTHER(S):______

MEDICAL HISTORY

APPLICANT’S MEDICAL HISTORY – OPERATIONS AND OTHER HOSPITALIZATIONS:

DATETYPE OF OPERATIONTREATMENT

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PLEASE LIST ALL CURRENT MEDICTIONS WITH THEIR TRADE NAMES:

NAME OF MEDICATIONDOSAGE/FREQUENCYREASON

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MEDICAL PROBLEMS:

_____ HEART ATTACK_____ SPLEEN DISEASE_____ ASTHMA

_____ ANGINA_____ LIVER DISEASE_____ DIABETES

_____ PACEMAKER_____ GASTRIC DISEASE_____ THYROID

_____ ARRYTHMIA_____ BOWEL DISEASE_____ BLINDNESS

_____ HIGH BLOOD PRESSURE_____ LUNG DISEASE_____ DEAFNESS

_____ LOW BLOOD PRESSURE_____ BRONCHIAL DISEASE_____ VENEREAL DISEASE

_____ KIDNEY DISEASE_____ ALLERGIES_____ PAGET’s DISEASE

OTHER PROBLEMS (PLEASE SPECIFY):

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PLEASE GIVE DETAILS OF CHECKED ITEMS:

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NEUROLOGICAL PROBLEMS:

_____ HEAD INJURY WITH_____ BRAIN SURGERY_____ STROKE

UNCONSCIOUSNESS

_____ HEAD INJURY WITHOUT_____ MIGRAINE_____ SPEECH DISORDER

UNCONSCIOUSNESS

_____ MENINGITIS_____ DIZZY SPELLS_____ FLACCID OR SPASTIC

_____ ENCEPHALITIS_____ EPILEPSY/SEIZURES_____ APPLICANT WAS AN

AMATEUR OR

_____ POLIOMYELITIS_____ LOU GEHRIG’s DISEASEPROFESSIONAL BOXER

_____ MULTIPLE SCLEROSIS_____ PARKINSON’S DISEASE

OTHER NEUROLOGICAL PROBLEMS (PLEASE SPECIFY):

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PLEASE GIVE DETAILS OF CHECKED ITEMS:

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PSYCHIATRIC PROBLEMS:

APPLICANT’S HISTORY OF PSYCHIATRIC PROBLEMS:

_____ PSYCHIATRIC HOSPITALIZATIONS ______DEPRESSION _____BIPOLAR DISORDER

_____ PSYCIATRIC TREATMENT ______ALCOHOLISM

_____ SCHIZOPHRENIA ______DRUG ABUSE

PLEASE SPECIFY:______

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APPLICANT’S FAMILY HISTORY OF PSYCHIATRIC PROBLEMS:

_____ PSYCHIATRIC HOSPITALIZATIONS ______DEPRESSION _____BIPOLAR DISORDER

_____ PSYCHIATRIC TREATMENT ______ALCOHOLISM

_____ SCHIZOPHRENIA ______DRUG ABUSE

PLEASE SPECIFY:______

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SUBSTANCE USE

HAS THERE EVER BEEN A PERIOD IN YOUR LIFE WHEN YOU HAD THREE OR MORE DRINKS PER DAY FOR THREE OR MORE DAYS IN A ROW?

___ YES ___ NO IF YES, HOW LONG AGO?______WHEN WAS THE LAST TIME? _____

HAVE YOU USED DRUGS LIKE MARIJUANA, COCAINE or HALLUCINGENS?

TYPE? ______

HOW OFTEN? ______

WHEN DID YOU LAST USE? ______

DO YOU TAKE VALIUM, SLEEPING PILLS, TRANQUILIZERS OR PAIN KILLERS?

TYPE? ______

HOW OFTEN? ______

WHEN DID YOU LAST USE? ______

WHY DID YOU CHOOSE TO PARTICIPATE IN THIS RESEARCH STUDY?______

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