NEUROPSYCHOLOGICAL ASSESSMENT SUMMARY

NAME: Date: AGE:

Tests Used Scores Strengths Difficulties

Screen
CAMCOG

Attention

Perception

Memory

Executive

Other

EMOTIONAL STATUS
Observed:

Reported:

Formal measures:

Examiner Observations including: attention, behaviour, language,

performance style (e.g. self-instruction, persistent, speed, checking), anxiety
about testing
 BACKGROUND
Name:

Age:

Sex:

Medical history (Medication, Mental health, Serious illness, Head injuries,

accidents esp. when lost consciousness)
May 1946 Born in York, mum idolized him, run out of school when he was 5 (the gates),
worked at choc factory for 15 years enjoyed job, met wife (age 29) nearly 45 years
ago (who had already been married and had children) – brought them up as his
own.
Jan 1963 Viral meningitis NOS (XE0R7), paralyzed on one side (but regained movement) and
he thought he was going to die. Remembers the pain.
1964 Motorbike accident (6 months after), helmet cracked (saved him) was conscious at
one point “a man saying don’t move the ambulance will be here soon”. Broke his
arm, was not admitted.
Jan 1965 Epilepsy (F25..), doctors said it could be related to the meningitis. Had a brain scan
in Leeds (reports) “there is brain damage”.
In his 20s Bicycle accident, hit his head again “a lot of stiches”, “head swelled up”.
1973ish started going out with Jane
Jan 1994 Blindness, one eye, unspecified (F4950), fell 15 feet – two broken arms, damage to
his eyesight and optic nerve. Hospitalized 2 weeks.
CTHEA CT HEAD Exam Status: Completed Reported By: DR D J WILKINSON Date: 11-
JAN-1994 00:00
Report Text: Emergency - Serial cuts were made from the base to the vertex. The
midline structures are normally positioned. The ventricles are normal and there is no
evidence of an intra cerebral bleed. There is extensive left fronto parietal soft tissue
swelling. We did not make specific cuts through the orbits, but no gross lesion is
identified, though I understand that there may be a visual defect. ASC
Jan 1997 Sinus tachycardia (G57y7),
Oct 2002 Dupuytren hand fasciectomy
2003 Wife admitted into hospital in Hull, Fred visited on a regular basis – triggered
exacerbation of anxiety.
2004 consultation with Consultant Clinical Psychologist in Neuropsychology (Diana
Teseland)
Aug 2005 Gallbladder calculus (X308A),
Sep 2013 Psychology CMHT with trainee CP (psychoeducation, behavioural experiments)
Nov 2013 Accidental drug overdose (XSEZy) – ‘frisium’ ??
Apr 2016 Jehovah's Witness (1357.),
Oct 2019 Agoraphobia (X00SV),
Mar 2020 ACE II completed: Score 89/100 (Att: 16/18; M 19/26; Fluency: 12/14; Lang: 26/26;
VSP: 16/16)
Family Medical History: (Mental health, Serious illness, Neurological
difficulties)
Grandma, mum and two sisters had dementia (thinks they all had different types; all passed
away). Mum would repeat herself and did not know where she was. Joyce (sisters) took
medication and ‘it slowed it down’. Frieda (youngest sister), “started losing words” but does
not feel it is the same as his problems. No known family history of epilepsy.

Personal history (Marital history, Children, Siblings, Family problems, Social)

Jean’s children in their forties Kevin (47), Gary (46), Patrick (41). No family problems
reported. Report have had lots of friends, but have lost contact with them over the years.
Would go out on the weekends with friends, were not big drinkers.

Education/Occupation (Cognitive style, preferences, aptitudes, any

problems at school, strengths)

Fred went to school until he was 15 years old, enjoyed school. Favorite subjects gym and art
(would put on a display). Reported he like English, History and Geography was a ‘terrible
speller’ and found Math a bit more difficult.

(line work??) Worked at a Chocolate Factory with machines for 15 years, the job ‘pretty
easy’. When he got to 18 also worked some night shifts (10hours) - found this good “I am
very good on the night”.

After, ad hoc work with a friend on a house as a laborer, plumbing etc. Guest house…..

After he fell ok in terms of income, were building the guest house.

Psychological (emotional style, mental health)

Family (Emotional style, Physical/Mental Health)

Social (Friends, Spare Time, and Interests/Hobbies)

Reports that he has no hobbies. Will from time to time write poems and stories. Used to
enjoy reading in the past (Jean thinks that since he has one eye he doesn’t).

Other (Smoking Now/Past; Alcohol consumption; Sleeping patterns; Appetite)

Fred explained that he stopped drinking when he was 30 “it does not help with the brain”.
Fred has been a smoker. No recreational drugs.

REASON FOR REFERRAL (expectations, concerns)

Presenting Difficulties
Client aims (What difficulty is impacting most on your life? What would the
client like to get from the assessment?)

Purpose of Testing e.g. look for organic origin, assessment of current level
of functioning etc.

SUBJECTIVE CONCERNS/Reported or Observed difficulties (S,R,O):

1. Sensory/Perception: no sensory difficulties identified. Reports that his hearing

is okay, may ask “what was that” – attributed to lack of attention/concentration.

2. Motor (Walking, Moving, Co-ordinating, Clumsiness): Right handed has

some difficulty with fine movement in his left hand – feels associated with
meningitis, and movement got worst after the fall. Gradually couldn’t move the
arm as well and do things with his left hand. Reports some sensation difficulties
and that

3. Attention (sustained….): difficulty sustaining attention e.g. lose threat of

conversation. Finds it harder to multitask compare to Jean.

4. Memory (long-term, short-term, recall, recognition, types of memory

[episodic, autobiographical, procedural]): short-team memory difficulties, no
long-term difficulties. No procedural difficulties.

5. Language (Repetition, Lose track of conversation, Pronunciation difficulty,

can’t think of a word): Lose track of conversation and difficulty thinking of
words (e.g. setae). No pronunciation difficulties.

6. Visuospatial (feeling disorientated, confused when looking at things, get

lost, mix things u): only has vision on one eye - reports that this brings some
problems e.g. bowl being upside down and not noticing it, or not being able if it’s
a crater or a mountain. Has no depth vision.

7. Behaviour

8. Emotional

9. Social relationships

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