Neuropsychological Evaluation Report (Concussion/mTBI)

Document title: Neuropsychological Evaluation Report

Patient name: [Patient name]

Date of birth: [Date of birth]

Age at evaluation: [Age]

Gender: [Gender]

MRN: [MRN / not applicable]

Preferred language: [Preferred language] (Include interpreter use if applicable)

Evaluation date(s): [Date(s) of evaluation]

Feedback date: [Date / not applicable]

Location: [Clinic/facility name and setting]

Examiner: [Examiner name, degrees, credentials, licensure state and number]

Referral source: [Name, role/title, organization, contact information]

Referral type: [clinical / occupational or academic clearance / medicolegal]

Consent and dissemination: [Informed consent statement, limits of confidentiality reviewed, authorization to release confirmed. Report recipients listed.]

Referral Questions

• [Referral question 1] (Frame each question as specific and answerable)
• [Referral question 2]
• [Additional referral questions as applicable]
• [Time since injury and symptom phase: acute / subacute / persistent]

Sources of Information

Records Reviewed (List each source with date; state "not available for review" if applicable)

• [Record source and date]
• [Record source and date]
• [Additional records]

Collateral Informants

• [Name/initials, relationship, date, mode of contact, key information obtained]

Measures Administered

• Performance validity tests: [List measures]
• Symptom validity measures: [List measures]
• Cognitive measures: [List tests organized by domain]
• Emotional/behavioral measures: [List inventories/scales]

History of Present Injury

[Narrative description of index event: date, mechanism, setting, forces involved, protective equipment, immediate symptoms. Document acute injury markers with explicit information source (records vs self-report): alteration of mental status, loss of consciousness with duration, post-traumatic amnesia with duration, acute neurologic signs, acute care received.] (Do not infer LOC, PTA, or imaging findings without documentation; state uncertainty and source explicitly.)

Timeline of key dates

• [Injury date]
• [Symptom onset and peak]
• [Return-to-activity attempts and responses]
• [Treatment milestones]
• [Work/school reintegration milestones]

Symptom trajectory: [Description of onset, peak, improvement/worsening phases, triggers, mitigating factors, current status. Note exertional intolerance, screen intolerance, motion sensitivity patterns.]

Prior Concussion/TBI History

[Number of prior head injuries, approximate dates, mechanisms, recovery duration, complications, and whether full recovery occurred before subsequent injury. If none, state: "No prior head injuries reported."]

Relevant Background

Medical/Neurologic History: [Migraine/headache history, seizures, sleep disorders, ADHD, learning disorders, vestibular/vision issues, chronic pain, other neurologic conditions]

Mental Health History: [Mood/anxiety/PTSD history, onset, course, treatments, trauma history if relevant and patient consents]

Medications and Substances: [Current medications and doses, recent changes, caffeine/nicotine/cannabis/alcohol use patterns]

Developmental/Educational History: [Learning supports, IEP/504, academic demands, highest education level]

Occupational History: [Current job role and cognitive/physical demands, screen use, safety-sensitive tasks, current work status]

Social Context: [Living situation, supports, major stressors, litigation/compensation context if relevant to interpretation]

Current Symptoms and Functional Impact

(Document severity, frequency, triggers, mitigating factors, and functional consequences for each domain. Include standardized symptom scale scores when available.)

Physical/Somatic: [Headache characteristics, dizziness, nausea, photophobia/phonophobia, visual symptoms, balance, neck pain]

Cognitive: [Attention, processing speed, mental fatigue, memory, word-finding, multitasking difficulties]

Emotional: [Irritability, anxiety, depression, stress reactivity, PTSD symptoms]

Sleep/Fatigue: [Sleep onset, maintenance, quality, total sleep time, daytime fatigue]

Functional Impacts: [Work/school performance, ADLs, exercise tolerance, driving, social participation]

Symptom scale scores: [Measure name, total score, relevant subscales]

Behavioral Observations

[Appearance, orientation, speech/language, mood/affect, thought process, insight/judgment. Note observed fatigue, pain behaviors, photophobia accommodations, breaks taken, frustration tolerance, task engagement/persistence.]

Testing conditions: [Standard / deviations noted] (If non-standard, document deviations such as interpreter use, suboptimal sleep, elevated pain, medication timing, environmental factors, and anticipated impact on performance.)

Validity Assessment

Performance validity: [List PVTs and embedded indicators; summarize pattern as consistently adequate / variable / invalid]

Symptom validity/response style: [Note elevations suggesting over-reporting, under-reporting, or inconsistent responding; integrate with behavioral observations]

Interpretability statement: [Results are considered a valid estimate of current functioning / Results likely underestimate abilities due to (specify reason) / Results are not interpretable for cognitive diagnosis] (If validity is mixed, specify which domains remain interpretable. Do not infer focal cognitive deficits from low scores when validity is compromised.)

Test Results

(Report standard scores and percentiles with consistent qualitative descriptors: Exceptionally Low, Below Average, Low Average, Average, High Average, Superior, Very Superior. Follow scores with interpretive narrative addressing intra-domain patterns and modifiers.)

Attention/Working Memory

• [Test name]: [Standard score, percentile, descriptor]

Interpretation: [Brief synthesis of performance pattern and clinical relevance]

Processing Speed

• [Test name]: [Standard score, percentile, descriptor]

Interpretation: [Brief synthesis]

Learning and Memory – Verbal

• [Test name]: [Standard score, percentile, descriptor]

Interpretation: [Acquisition vs retention vs retrieval profile]

Learning and Memory – Visual

• [Test name]: [Standard score, percentile, descriptor]

Interpretation: [Brief synthesis]

Executive Functions

• [Test name]: [Standard score, percentile, descriptor]

Interpretation: [Strengths/weaknesses, error patterns]

Language

• [Test name]: [Standard score, percentile, descriptor]

Interpretation: [Brief synthesis]

Visuospatial/Constructional

• [Test name]: [Standard score, percentile, descriptor]

Interpretation: [Brief synthesis]

Motor/Sensory (If assessed)

• [Test name]: [Standard score, percentile, descriptor]

Interpretation: [Brief synthesis]

Emotional/Behavioral Measures

• [Measure name]: [Scores and interpretation]

Interpretation: [Synthesize mood/anxiety/stress burden and likely impact on cognition and recovery]

Integrated Interpretation

(Provide biopsychosocial formulation addressing relative contributions. List top contributors first.)

• Concussion/mTBI pathophysiology: [Plausibility given timeline and injury characteristics]
• Sleep/fatigue factors: [Contribution to cognitive efficiency and symptoms]
• Headache/migraine/pain: [Impact on processing speed, attention, endurance]
• Mood/anxiety/PTSD: [Influence on attention, memory, symptom reporting]
• Medication/substance effects: [Sedation, activation, anticholinergic load]
• Vestibular/oculomotor factors: [Screen intolerance, motion sensitivity]
• Contextual stressors: [Occupational, academic, family, medicolegal factors]

[Narrative synthesis integrating test performance, self-reported symptoms, behavioral observations, and contextual factors. Include differential diagnostic considerations and prognostic modifiers.]

Diagnoses

• [Concussion/mild traumatic brain injury]: [meets criteria for / history consistent with / insufficient information to confirm] (State basis: records vs self-report)
• [Additional diagnoses with brief justification]

Recommendations

(Include only categories relevant to patient's situation)

Education

• [Expected recovery trajectory and reassurance]
• [Symptom-limited activity principles and pacing strategies]
• [Re-injury avoidance counseling]

Return-to-Work (If applicable)

• [Graded schedule with hours and progression intervals]
• [Break frequency, screen time limits]
• [Environmental modifications]
• [Task modifications]
• [Safety-sensitive restrictions]
• [Criteria for progression or regression]

Return-to-School/Return-to-Learn (If applicable)

• [Academic accommodations: reduced load, extended time, rest breaks]
• [Screen reduction and alternative formats]
• [Note-taking and testing environment modifications]
• [School contact to receive recommendations]

Return-to-Sport/Exercise (If applicable)

• [Supervised graded progression per consensus guidelines]
• [Contact/collision risk counseling]
• [Criteria to advance, hold, or regress stages]

Symptom Management Referrals

• [Sleep optimization]
• [Headache management]
• [Vestibular/oculomotor/vision therapy]
• [Cervical rehabilitation]
• [Psychotherapy and/or psychiatric consultation]
• [Medication review]

Cognitive Strategies

• [External supports: calendars, reminders, lists]
• [Pacing and fatigue management]
• [Attention scaffolds and workspace modifications]

Follow-up

• [Timing for reevaluation]
• [Criteria for earlier contact: symptom worsening, red-flag signs, safety concerns]

Feedback Session

(If feedback provided separately from evaluation)

[Date, attendees, topics reviewed, patient questions addressed, agreed-upon next steps, safety counseling including red-flag symptoms requiring urgent care]

Signature

[Examiner name, degrees]

[Credentials and licensure]

[NPI if applicable]

[Institution, address, phone, secure fax, email]

Report distribution: [Patient, referring provider, others with authorization]