Sample description of problem – Adult


This is a sample description of John, a 57 y.o. adult male, describing his concerns.

Please John describe what problems you want to address with this evaluation; specifically describe what you and those close to you have noticed. Please write as much as you need to explain your concerns.

I am having a hard time understanding what people say and remembering things. I also feel dizzy, I have no energy, and cannot seem to understand  what I read. Sometimes I have to read something many times and I still don't get the main idea. I also get distracted easily. I have also noticed that on some days I have hand tremors, I am irritable, and on the verge of an emotional outburst. My wife also has noticed different changes in me: I am late to work, I am having a hard time driving back home, and I skip words when I read our mail. 

Last week for example I was at a wedding and a friend that I have known for a long time asked me about my wife and how she is doing with her new job at the bakery: it took me some time to remember where she is working. Sometimes I feel I have no knowledge of what people ask me. 

I have also noticed that at times I have a hard time pronouncing some words, and this has gotten worse since my last year in college. Sometimes when I go out with friends they have to guess what I am trying to say, but it's easy to hide it because I was not born here and english is not my native language, however I have lived in America for 35 years and shouldn't have these issues.

I want to know if I have memory problems, if I have ADHD, or if I have a learning disability. I want to know what to do to turn my life around.





In this paragraph John describes his concerns, and how they are affecting his life at work, at home and in social contexts. 

In your opinion John, when did the problem start?

I think it all started when I was 6 and in grade school. I remember I was having a hard time to read and I could not concentrate. I had the same problem when I was in high school, I was 15, my grades were always low and I struggled to pass classes.

I also had problems with sports. When I was 19 I tried to take some classes in college to help raise my grades, so I registered for baseball and tennis: I remember I could not catch-and-throw the baseball and I had similar problems when playing tennis. I was good however in science. 



In this paragraph John describes when the issues he wants to address in the evaluations started, which cognitive domains are involved and how much it has impacted his daily life. 

What have you done so far to deal with these issues?

I was in therapy when I was 16 (1994), I met with the social worker once a week for about 6 months. Then I stopped because I did not see any change, and I started again when I was in college, I think I was 20 then (1998), I think I met with the therapist once a week for about 1 year and then once every 2 or 3 weeks for about 6 months. She then suggested me to check with my primary care physician and he put me on medication for ADHD, it helped a lot but I don't think it work as much as I hoped.

I am now on different medications for ADHD, anxiety, and depression and I see my therapist once a month.



In this paragraph John describes what he has done, when, and how effective it has been.