Sample Template

                                                          NEUROPSYCHOLOGICAL ASSESSMENT REPORT



Patient Name:MR:

Date of Testing:Examiner:Gregg Richardson, PhD

Referral:  The patient, a -year-old, -handed, -born occupation of descent, is referred by xxx for evaluation of xxx.

HPI:  The patient reports that

S/he usually awakens am, arises, nap during the day, is usually in bed , asleep, the night.  he reports a appetite, has lost or gained significant weight over the past year, appear either obese or undernourished .  Daily mental and physical energy are.  Exercise .

he lives with in their home of years.  H live in the area and see h. he socializes with friends.

Personal History: The patient reports that he was born on in.  To the best of h knowledge h mother’s pregnancy and delivery were without complication, and he achieved normal developmental milestones.  H schooling started and progressed normally; a student, he also extracurricular activities.  After graduating from high school he. he married children

Family History: The patient reports that h father () h mother ().  siblings.  (Family) psychiatric, neurological, substance abuse.

Medical History: The patient reports no unusual illness or injury as a child or teen.


Current medications include .

supplements, herbs or alternative medications

he reports psychotherapy.

substance abuse.

Test Behavior:  The patient appeared on time, dressed and groomed, and was with the examiner.  he described h mood as “” and displayed an appropriate range of affect using vocal tone, facial expression, and body language.  he was aware of the purpose of testing and expressed interest in learning the results.  he exerted full effort on all tests, and this set of results is considered valid.

Tests Administered (NOTE: This template is written with the following tests in mind; you should modify your own report according to the tests actually administered):

Kaplan Baycrest Neurocognitive Assessment (KBNA)

Learning and Memory Battery (LAMB) – Taylor Figure

Trails A and B (HRNB)

Go/No-Go and Three-Position Hand Sequence

Stroop Color and Word Test

Patient Health Questionnaire (PHQ-9)

Attention/Concentration:  The patient was xxx in this domain.  he was oriented, able to perform a variety of rote and novel mental sequencing tasks with accuracy (%ile overall), and to complete a variety of verbal and visuospatial tasks—all without evidence of impersistence or of significant internal or external distractibility.

Processing Speed:  The patient xxx in this area.  Mental sequencing tasks were performed in of the time allotted.  Trails A was at the %ile, and Trails B at the %ile.  fluency.  primary Stroop scores were .  he performed at adequate speed on untimed tasks.

Language:  The patient xxx in this domain.  he spoke fluently in conversation, with good prosody, and without paraphasias or significant problems finding words.  H oral description of a situation picture employed adequate phrase length and grammar, and provided adequate descriptions of essential persons, actions, implied relationships, and implied prior and future events.  he had no difficulty following instructions and formal auditory comprehension was without error.  repetitions .  Confrontation naming was.  Phonemic fluency was at the %ile, and semantic fluency at the %ile.  Single-word reading was WNL for regular, irregular and pseudowords, and sentence-reading .

he was able to perform both of the arithmetic calculations described in the readings quickly and accurately.

Visuospatial:  The patient xxx in this domain.  H direct copy of a complex figure displayed strategy, size, proportion, placement of detail, precision.  A freehand clock drawing displayed good strategy, an accurate setting, proportionally spaced numbers, and clear differentiation of hand lengths.  he had no difficulty reading clocks with or without numbers.  On the situation picture, he clearly perceived a single scene with three areas of activity.

Motor:  The patient xxx in this domain.  he neither reported nor displayed problems with gait or balance.  Handwriting and drawings suggested no tremor or other manual dyscontrol, and he displayed no disinhibition on a go/no-go task.  he had no difficulty learning a sequence of three hand-positions and transferring this sequence to h non-dominant hand.  he had no difficulty learning a pattern of bilateral, simultaneously alternating hand positions.  Manual ideomotor praxis was intact bilaterally for intransitive and transitive tasks, and buccofacial praxis for tasks and emotional expression.

Executive Functions:  The patient xxx in this domain.  he had no difficulty initiating, continuing, or terminating tasks appropriately.  Complex figure and clock drawings displayed immediate and consistent awareness of the larger gestalts organizing the figures, and he used semantic clustering when learning a word list.  Neither Trails task contained errors in sequencing or set-switching.  Judgment in hypothetical emergencies was sound.  H ability to discern different sets of visual objects from within the same larger group was WNL.  H ability to inhibit an overlearned response when a novel one was required (Stroop interference) was at the %ile, word-reading and color-naming.

Memory:  The patient xxx in this domain in the verbal and visual modalit.  Motor learning (see above) was based on limited testing.

Total recall over four learning trials of a word-list was at the %ile, with repetitions intrusions; h learning slope () and use of semantic clustering ().  Delayed free recall was % of trial-four recall (/), and delayed cued recall /; neither delayed trial included repetitions or intrusions, and overall delayed recall (hits) was at the %ile.  Yes/No recognition memory for the word list was , including /12 hits and /24 false positives.

Visual sketchpad memory (for dots arrayed on grids) was at the %ile.  Trial-one recall for the complex figure was at the %ile, trial-four recall at the %ile, and delayed recall at the %ile.  Recognition memory for drawings used earlier in the naming task included /20 hits and /20 false positives ().

Emotional Factors:  The patient reports.  Responses to the PHQ-9 included , suggesting

Summary and Conclusions:  The patient, a -year-old

Discussion:  The patient’s overall history, presentation and test results suggest

Plan:  Results discussed with patient.  Copy to .

Gregg Richardson, Ph.D.

Clinical Neuropsychology

I would like to thank Gregg Richardson, Ph.D., for contributing this sample  template as a teaching tool for students using