C J Long
|Charles J. Long Ph.D., ABPN||(901)678-3036 --- (901)678-2821|
|Neuropsychologist||Fax Number: (901)678-2692|
|Name:________X_________||Referred By: _________________|
|Test Date:_________________||Date of Injury: _________________|
|DOB:_________________||Report Date: _________________|
|Age:_________________||Request: Neuropsychological Assessment|
|Dominant Hand:_________________||Medication: _________________|
|Occupation:_________________||Marital Status: _________________|
|Neuropsych Tech:_________________||File I.D. No. _________________|
Focal characteristics If present. NOTE: this raises a flag for neurosurgeons so don't make a point of focal characteristics unless it is clearly justified.
Reaction time testing indicates that _________________X's speed of processing is ________________.
Intellectual assessment with the Wechsler Adult Intelligence Scale - Revised (WAIS-R) reveals that _________X________ is currently functioning within the _________________ range of intelligence, with _________________ significant discrepancy between verbal and performance abilities.
Memory assessment reveals that _________X_______ is functioning within the _________________ range for short-term memory abilities. Memory consolidation tasks indicated long-term memory abilities in the _________________ range. ________X______ was able to recall % of the material he had learned previously.
Results of the Minnesota Multiphasic Personality Inventory (MMPI) are similar to a profile of individuals who _________________
Situational factors:Explain significant situational factors that might have influenced the neuropsychological performance.
As a result of the above information gained from a full day of neuropsychological testing and from background information provided by _________________ , the following conclusions are made:
(2) Consistency with presence symptoms.
(3) Duration of post-traumatic amnesia (PTA) is normally used as a measure of severity of head trauma.
|Minimal||1-5 min||1 month|
|very mild||5-60 min||1 month|
|Mild||1-24 hrs||1-3 months|
|Severe||8-28 days||11-24 months|
|Very Severe||>29 days||>24 months|
(5) Relationship of above factors to symptoms.
(6) Prioritize organic, emotional, and situational factors with regard to importance.
(7) Describe interactions of the above.
(8) Relationship fo test findings to predictions of work/school performance.
(9) When an individual has a slower than expected recovery rate identify barriers to recovery.
Adjust to what is available and practical.
The reason for the referral is to determine current level of functioning.
The following background information was provided by________________
Nature, time of onset, and course of symptoms
previous medical history
previous psychological history
environmental factors: social support, job description, academic level, available resources, stresses and/or barriers to recovery
.Fine and gross motor movements (physical disabilities)
There was no indication of speech defects; ________X_________ was able to respond to questions and express _________________ own thoughts both logically and with clarity.
No problems with comprehension were apparent; instructions were grasped quickly, and few repetitions were required.
Attention and concentration.... attitude and motivation During the day-long testing session, ________________X 's personal presentation was one _________________
of...._________________ ....(attitude) friendly and cooperative
__X__ appeared to answer all questions openly and honestly
He seemed to give best efforts on all tasks.
For the above reasns, it is believed that ________X________ performed to the best of their ability during the entire testing and that the test findings represent a valid estimate of their current level of functioning. (If not, qualify and relate problems to performance).
Psychomotor: Tapping speed was in the _________________ range, grip strength was in the _________________ range. performance on tests assessing psychomotor speed and eye-hand coordination was in range.
Perceptual-Motor: Perceptual motor evaluation required the tracking of numbers, letters, and numbers and letters in alteration. These tasks assess psychomotor speed as well as eye-hand coordination. _________________ performance tracking numbers was in the _________________ range. Integrative: On the Tactual Performance Task, _________________ was required to place differently shaped wooden blocks into their appropriate spaces on a board while blindfolded. This complex integrative task required psychomotor skill as well as tactual and kinesthetic perception. On this task, performed within the range. Memory for the shapes of blocks was within the range and memory for their location on the board was in the _________________ range.
Language: Basic language functioning was assessed with the Thurstone Word Fluency Test which required to generate as many words as possible falling within certain constraints (e.g., "S" words). On this task, performance _________________
On the aphasia screening task,
Intellectual: Intellectual assessment with the Wechsler Adult Intelligence Scale - Revised (WAIS-R) revealed that _________________ is currently functioning within the _________________ range of intelligence, with _________________ significant discrepancy between verbal and performance abilities.
Memory: Memory assessment reveals that _________________ short-term memory functioning is within the range. Memory consolidation, assessed in a one-hour-delayed recall of previously learned information, reveals long-term memory in the range. _________________ was able to recall % of the material had learned previously.
Personality: Results of the Minnesota Multiphasic Personality Inventory (MMPI) are similar to a profile of individuals who _________________
significant amount of emotional distress.
Endorsed items relate to
strategies foe coping with stress; effectiveness of strategies.
relationship of emotional factors to symptoms and test performance
Thank you for allowing us to evaluate this interesting case. _____________X's data will be maintained in our files for your future reference.
Charles J. Long, Ph.D. Neuropsychologist