Family Member & Caregiver Questionnaire for Tucson Neuropsychology
Please fill out this form about your family member as part of their evaluation with Tucson Neuropsychology Associates.  

This information will help us to better understand his/her abilities and needs.  Please describe any difficulties that you have noticed in the following areas, the type of help he/she needs with those tasks, and how long the difficulties have been going on.  If the person has no problems in that area, write "no problems".  Thank you!
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Name of Patient
Name of person completing this form
Your relationship to the patient
Please provide your email and/or telephone number so we can contact you if we need clarification on anything.
Walking / Movement / Balance (example: falls, tremors / shakiness, shuffling walk, unable to walk far, unsteady)
Daily self-care (bathing, dressing, grooming, bathroom use / toileting, eating, etc.)
Meal planning, preparation & cooking
Household chores (cleaning, laundry, etc.)
Driving
Finding way around
Shopping (finding items, making good choices, paying, etc.).
Using money, understanding value & cost
Paying bills
Making financial decisions
Making appointments & keeping appointments
Attention, concentration & focus
Forgetfulness, memory, learning new information
Comprehension & understanding information
Making decisions & solving problems
Taking medications
Understanding medical information & making medical decisions
Knowing what to do in a crisis
Language & communication (expressing self, finding the right words, making sense, writing, reading, etc.)
Controlling impulses & behaviors (saying or doing things without thinking first, etc.)
Social behaviors (behaving appropriately in public, being at risk of being taken advantage, trouble getting along, poor boundaries, etc.)
Patience, frustration, losing temper
Changes in personality
Depression or anxiety
Thinking unusual things or out of touch with reality
Periods of confusion
Energy level or activity level
Sleep
Appetite or eating
Any time of day or situation when problems are more noticeable?
Any other difficulties not listed above?
Any other safety concerns not listed above?
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