Neuropsychological Assessment Behavioral Observations

Patient Name*

First Last

Examiner Name*

If other, provide name below

First Last

Date of testing*

Were there multiple days of testing?*

Yes
No

Second day of testing (if multiple days)

Number of hours tested*

Please enter a number from 1 to 12.

Number of hours scored*

Please enter a number from 1 to 12.

Arrival

Did the family arrive on time?*

Yes
No

Who accompanied the patient?*

Alone
Mother
Father
Grandmother
Grandfather
Other family member

Separation*

Easily
Normal
Difficult

Appearance

Dress*

Casual
Formal
Disheveled
Inappropriate

Grooming*

Neat
Appropriate
Unkempt (e.g., hair not combed, spills)

Assistive Devices

Check all that apply*

Glasses
Contacts
Hearing aid
AAC (device)
None

Handedness

Select below:*

Right
Left
Ambidextrous

Hearing & Vision

Visual acuity*

Adequate
Poor

Did child hold materials close to face to see them?*

Yes
No

Hearing: Was examiner required to use a loud voice?*

Yes
No

Motor Skills

Were the child's motor skills/gait perceptually judged as typical?*

Yes
No

If no, provide more details below.

Was the child's ambulation perceptually judged as typical?*

Yes
No

If no, provide more details below.

Did the child present with any unusual mannerisms?*

Yes
No

If yes, provide more details below.

Level of Arousal

Select below*

Alert
Lethargic
Non-responsive

Interpersonal Style

Select below*

Easily engaged
Guarded

Select below*

Active
Passive

Select below*

Friendly
Hostile

Select below*

Appropriate
Disinhibited

Provide examples of interpersonal style below*

Attitude Towards Testing

Select below*

Cooperation Level

Select below*

Full (cooperative - interested/involved)
Less than full (Uncooperative - uninvolved or resistant)
Fluctuating

Provide examples of cooperation level below*

Effort Level

Put forth good effort:*

Consistent
Inconsistent (variable)
Minimal
Improves as assessment progresses

Provide examples of effort level below*

Work Habits

Response time*

Slow
Medium
Fast

Movements*

Neat
Clumsy
Careless

Persistence*

Persistent
Gives up easily

Planning/thought process*

Trial and error
Planned and deliberate

Impulsive?*

Yes
No

Perseverative?*

Yes
No

Easily distracted?*

Yes
No

Lost set?*

Yes
No

Provide examples of work habits below*

Self-Monitoring

Does child self-monitor work?*

Yes
No

Is child aware of failure?*

Yes
No

Reaction to failure*

Provide examples of self-monitoring below*

Encouragement

Response to encouragement*

No change
Increased
Decreased
Needs frequent encouragement

Directions

Able to understand directions?*

Yes
Expl
No

Able to remember?*

Yes
No

Able to follow directions?*

Yes
No

Requires prompts/redirection?*

Yes
No

If yes, explain frequency of prompts/redirection

Provide examples of following directions below*

Expressive Language

Spontaneous*

Yes
No

Fluency*

Fluent
Halting
Non-fluent

Volume*

Loud
Soft

Pace*

Fast
Slow

Articulation*

Articulate
Reduced articulation

Other features: check all that apply*

Dysnomic
Paraphasic
Aprosodic
Perseverative
Tangential
Poor initiation
None of the above

Thought Process

Check all that apply*

Affect

Check all that apply*

Appropriate/full
Constricted
Restricted
Labile
Blunt
Flat

Mood

Check all that apply*

Euthymic
Euphoric
Depressed
Dysphoric
Anxious
Irritable
Angry
Apathetic
Tearful