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Neuropsychological evaluation questionnaire (SCLAK) |  |
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For your convenience please find a neuropsychological evaluation test. Please answer all the questions by indicating (Y) for yes and (N) for no. A yes to any of the questions listed below opens novel therapeutic possibilities to the symptoms you feel you are having.
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Name:
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______________________________ |
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Birth:
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______________________________ |
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Address:
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______________________________ |
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Sex (M-F):
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______________________________ |
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Telephone:
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______________________________ |
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Fax:
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______________________________ |
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Email:
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______________________________ |
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Prior diagnosis:
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______________________________ |
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Chronic use of medications (please specify):
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______________________________ |
Please indicate if you presently have or had in your past any of the symptoms listed in the questionnaire. Please answer all questions:
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Symptom |
Yes |
no |
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Sleep disorders?
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Super sensitivity to heat?
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Insensitivity to cool or cold weather?
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Super sensitivity to touch (By people or objects (shoes, shirts etc.))?
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Super sensitivity to noise or specific odors (Smells)?
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Eating disorders?
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Drinking habits of soft drinks and water (0-5-10-15 cups per day?)
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Speech disorders or stuttering?
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Bed wetting (After age 6 years)?
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Excessive blinking?
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Any sort of tics?
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Asthma?
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Allergies?
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Chronic “running nose", Bronchitis, Colitis, “Irritable bowel syndrome”(IBS)?
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Ocular disturbances (Temporal blurred vision or flashes in visual field)?
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Super or insensitivity to pain?
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Rage attacks or “explosive” behavior?
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Any form of reading disturbances (Dyslexia)?
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Any form of writing disorder (Dysgraphia)?
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Any form of calculation or arithmetic disorder (Dyscalculia)?
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Any form of attention disorder?
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Any form of social behavior disorders?
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Tendency to dysphoria and frequent low mood? Anxiety, fears, or phobias?
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Obsessive thoughts or compulsive rituals and behaviors?
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Fluctuation in intensity or nature of the relevant symptoms?
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Does any one of your 1st related relatives suffer from any of these symptoms?
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Does any one of your 1st related relatives have Tourette syndrome, Hyperactivity disorder, Obsessive compulsive disorder, learning disability, Autism, Asperger, Epilepsy or disturbances in EEG profile?
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A “Yes” answer to any of the questions listed above opens novel therapeutic possibilities to the symptoms you feel you are having. A fee of US 120$ will supply you with an evaluation report from the “Clinic for Advanced Psychology”, regarding novel therapeutic opportunities possible for you based on the Neuropsychological questionnaire.
Dr. A. Kessler, writing this page is a psychologist and a neuropsychologist in the “Clinic of Advanced Psychology”, engaged in treating and consulting patients as well as in clinical research, a member of the Israeli Psychological Association, an affiliate member of the APA and a member of the TIC consortium.
Tel: 972 8 946 5193, Facsimile: 972 8 946 5193, Email: kessler@geneplus.org
| The Information on this Website is not a subsitute for a Professional Aid. | Web Design: Ilay Avni |
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