This document is a neuropsychological impairment questionnaire completed by a doctor regarding a patient. It collects information about the patient's diagnosis, treatment history, symptoms, and functional limitations. Specifically, it asks the doctor to describe the patient's vision symptoms and limitations, estimate how often various work activities would be affected, and rate the extent to which the patient's condition impacts their ability to understand/remember instructions and maintain concentration/persistence.

1. NEUROPSYCH IMPAIRMENT QUESTIONNAIRE
Doctor: _____________________________________________
Patient: _____________________________________________
SSN: _____________________________________________
Date: _____________________________________________
Treatment:
a. Date of first treatment: _____________________
b. Date of most recent exam: _____________________
c. Frequency of treatment: _____________________
1. What is your diagnosis of your patient’s condition?
______________________________________________________________________________
______________________________________________________________________________
2. Prognosis:
______________________________________________________________________________
3. Describe any the symptoms due to the patient’s impairments?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. Describe your patients vision symptoms:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. 5. As a result of your patient’s impairments, estimate your patients vision limitations if your
patient were placed in a competitive work situation.
a. How often can your patient perform work activities involving the following?
Never Rarely Occasionally Frequently Constantly
Near Acuity
Far Acuity
Depth Perception
Accommodation
Color Vision
Field of Vision
b. Is your patient capable of avoiding ordinary hazards in the workplace, such as boxes
on the floor, doors ajar, approaching people or vehicles? Yes No
c. Does your patient have any difficulty walking up or down stairs? Yes No
d. Can your patient work with small objects, such as those involved in doing sedentary
work? Yes No
e. Can your patient work with large objects? Yes No
6. How much is your patient likely to be “off task”? That is, what percentage of a typical
workday would your patient’s symptoms likely be severe enough to interfere with
attention and concentration needed to perform even simple work tasks?
0% 5% 10% 15 % 20% 25% or more
7. Please describe any other limitations that would affect your patient’s ability to work at a
regular job on a sustained basis due to patient’s conditions?
________________________________________________________________________
________________________________________________________________________

3. 8. Are your patient’s impairments reasonably consistent with the symptoms and functional
limitations described in this evaluation?
__Yes ___No
9. As a result of these medical impairments, in your opinion, to a reasonable degree of
medical certainty, does your patient retain the functional ability to work in a competitive
environment, in even a sedentary occupation, on a full-time, 8 hours a day, 5 day a week
basis?
__Yes ___ No
10. Please describe the extent to which your patient’s condition and symptoms affect his/her
ability to do the following:
Not No Evidence No Ratable
Significantly Moderately Markedly of Limitation in on Available
Limited Limited Limited this Category Evidence
A. UNDERSTANDING AND MEMORY
1.The ability to remember location 1. 2 .. 3. 4. 5.
and work-like procedures.
2.The ability to understand and reme- 1. 2 . 3. 4. 5.
ber very short and simple instructions.
3. The ability to understand and reme- 1. 2. 3. 4. 5.
ber detailed instructions.
B. SUSTAINED CONCENTRATION AND PERSISTENCE
4. The ability to carry out very short and 1 2 3. 4. 5.
simple instructions
5. The ability to carry out detailed instruc- 1 2. 3. 4. 5.
tions.
6. The ability to maintain attention and 1. 2. 3. 4. 5.
concentration for extended periods.
7. The ability to perform activities within 1. 2. 3. 4. 5.
aschedule, maintain regular attendance,
and be punctual within customary toler-
ances.
8. The ability to sustain an ordinary rout- 1. 2. 3. 4. 5.
ine without special supervision.

4. 9.The ability to work in coordination with 1. 2. 3. 4. 5.
or proximity to others without being distr-
acted by them.
10. The ability to make simple work-related 1. 2. 3. 4. 5.
decisions
______________________ _____________________________________
Date Signature
Printed /Typed Name: ____________________________________
Address:________________________________________________
_______________________________________________________
_______________________________________________________