Neurological History Questionnaire

This questionnaire is intended to help us evaluate your neurological status. It is important that you answer as truthfully and thoroughly as possible. The questions are not designed to make you uncomfortable. The information you give here is kept strictly confidential, and does not become part of your medical records. It will not be disclosed to anyone but the investigators responsible for conducting the study.

If you answered yes to any of the preceding, please enter details below:

Enter details here

Have you ever...

9	been seen by a neurologist or neurosurgeon?		Select... Yes No Don't know
10	had a head injury involving unconsciousness? If so, for how long?		Select... No injury Under 5 mins Over 5 mins Don't know
11	required overnight hospitalization for a head injury?		Select... Yes No Don't know
12	had encephalitis or meningitis?		Select... Yes No Don't know
13	had a cancer other than skin cancer diagnosed in the past three years?		Select... Yes No Don't know
14	been resuscitated?		Select... Yes No Don't know
15	had a problem due to abuse of drugs or medication? If so, how recently?		Select... Never Within the last 5 years More than 5 years ago Don't know
16	been treated for alcohol or drug abuse?		Select... Yes No Don't know
17	had heart surgery?		Select... Yes No Don't know
18	had a heart attack?		Select... Yes No Don't know
	18b	If so, did you have a change in your memory, ability to talk, or solve problems 24 hours later?	Select... N/A Yes No Don't know
19	taken any medications for mental or emotional problems in the past five years?		Select... Yes No Don't know
20	been hospitalized for mental or emotional problems in the past five years?		Select... Yes No Don't know
21	received electroshock therapy?		Select... Yes No Don't know
22	had seizures?		Select... Yes No Don't know
23	had brain surgery?		Select... Yes No Don't know
24	undergone surgery to clear arteries to your brain?		Select... Yes No Don't know
25	had any illness which caused a permanent decrease in memory and cognition?		Select... Yes No Don't know
26	been diagnosed as learning disabled?		Select... Yes No Don't know
27	been placed in special classes at school because of learning problems?		Select... Yes No Don't know
28	been diagnosed as having a brain tumor?		Select... Yes No Don't know
29	had major surgery with general anesthesia?		Select... Yes No Don't know
	29b	If so, did you have any change in your memory, ability to talk or solve problems one week after surgery?	Select... N/A Yes No Don't know

If you can think of any other information which might indicate that you are neurologically unusual in any way, please describe it here in as much detail as possible.

		©1999-2002 by Mark Cohen and Richard DuBois Adapted from a form by National Institutes of Health
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