Neurocognitive Assessment Screening Questionnaire

This screening questionnaire is used to determine if a neurocognitive assessment is a necessary tool to assist our providers in developing a more tailored treatment plan to help resolve your pain. The results of this questionnaire are confidential and will be reviewed only by BACAS providers and discussed with you. It will not be shared with other external providers, agencies, or persons without your consent.

Use the scale of 0 (Not at All) to 5 (Very Often) to identify how frequently you experience any of the symptoms listed.

0: Not at all   |   1: Very Rare   |   2: Rare  |  3: Sometimes  |  4: Often  |  5: Very Often

Please answer the following questions honestly so that we may determine the best course of treatment for you.