Memory & Aging Clinic Questionnaire

Transcription

1 Memory & Aging Clinic Questionnaire The answers you give to the questions below will assist us with our evaluation. Each section is equally important so please be sure to complete the entire questionnaire. The patient may assist with medical history and medications. Today s date: Patient s name: Birthdate: Your name and relationship to person being assessed: Your address: Your phone (if different from patient s): Patient s occupation / employment: Main occupation? Is the patient retired and was this due to memory issues? Questions & Family Concerns: Use this space to write any questions or concerns that you would like to have addressed at the assessment or forwarded on to physician: General Orientation: In your opinion is the patient experiencing problems with memory? Yes No If Yes: Were these problems abrupt, gradual or other? When did you first notice the problem? Do the memory problems appear to be? Progressively worsening Yes No Worse on some days / better on others Yes No In your opinion, is the patient s memory impaired to such a degree that it would have interfered with activities of daily life a few years ago? Yes No

2 Are there any current or recent stresses or losses in the patient s life? MEDICAL HISTORY SECTION: MEDICATIONS: Please list the patient s medications below, including frequency and dosage OR include a medication list. Please include all vitamins and non-prescription medications. Medication Why taken Dose How often Does the patient take medications independently or are they given to patient by someone? Does the patient have any allergies to medications? If so, please list:

3 HEALTH HISTORY: Disorder Heart disease i.e. a-fib, surgery, pacemaker, etc. Lung Disease i.e. asthma, COPD, oxygen usage, etc. Kidney disease i.e. dialysis, etc. Diabetes and treatment Diet or medicine controlled? High blood pressure Diet or medicine controlled? Cancer - Please include location and date Liver disease Thyroid disease Hyper (underactive) or Hypo (overactive) High Cholesterol Diet or medicine controlled? Peripheral vascular disease Stroke(s) TIA or warning strokes, major stroke Parkinson disease Epilepsy Head injury Loss of consciousness? Developmental conditions Depression Current or past treatment Anxiety Current or past treatment Psychosis, hallucinations, or delusions Yes: please explain. If no, leave blank

4 Treatment for mood stabilization Bipolar disorder Schizophrenia Personality disorder Ever hospitalized for psychiatric reasons? Sleep disorder - i.e. snoring, apnea, waking multiple times, etc. Visual impairment - i.e. glasses, macular degeneration, glaucoma, etc. Hearing impairment - i.e. hearing aid and is it used? Abnormal gait - Uses walker, multiple falls, reason why. Smoking Current use, past use, years smoked Alcohol Current use, past use, alcoholism Street drugs Does he/she misinterpret objects (see things that you are not able to see), does this happen at a certain time of day? If yes, please explain below: Please list any other medical conditions that are not listed above: Does the patient have a family (blood relative) history of: Alzheimer s yes or no if yes, who? Dementia yes or no if yes, who? Parkinson yes or no if yes, who? Other neurological disease? yes or no if yes, who?

5 PERSONAL HABITS SECTION Please circle the appropriate answer Eating: No problem Independent, but slow or some spills Needs help to cut or pour; spills often Must be fed most foods Dressing: No problem Independent, but slow or clumsy Wrong sequence, forgets items Needs help with dressing Bathing: No problem Bathes self, but needs to be reminded Bathes self with assistance Must be bathed by others Toileting: Goes to the bathroom independently Goes to the bathroom when reminded; some accidents Needs assistance Has no control over either bowel or bladder Taking Pills or Medication: Remembers pills or medication without help Remembers if done is kept in special place Need spoken or written reminders Must be given pills or medication by others Does not regularly take pills OR don t know Interest in personal appearance: Same as always Interested if going out, but not at home Allows self to be groomed, or does so on request only Resists efforts of caretaker to clean and groom

6 PERSONAL HABITS SECTION continued Writing checks, paying bills or balancing a checkbook: Assembling tax records, business affairs, or other papers: Shopping alone for clothes, household necessities, or groceries: Playing a game of skill such as bridge or chess, working on a hobby: Heating water, making a cup of coffee, turning off the stove: Preparing a balanced meal: Keeping track of current events: Paying attention to and understanding a TV program, book, or magazine: Remembering appointments, family occasions, holidays, medications: Traveling out of the neighborhood, driving, or arranging to take public transportation:

7 BEHAVIOR SECTION Please answer the following questions based on changes that have occurred since the patient first began to experience memory problems. Please circle yes only if the symptom has been present in the past month. Otherwise, circle no. If yes, would you describe how it affects the patient as: mild = noticeable, but not a significant change; moderate = significant, but not a dramatic change; or severe = very marked or prominent, a dramatic change Does the patient believe that others are stealing from him or her, or planning to harm him or her in some way? yes or no mild, moderate or severe Does the patient act as if he or she hears voices? Does he or she talk to people who are not there? yes or no mild, moderate or severe Is the patient stubborn or resistive to help from others? yes or no mild, moderate or severe Does the patient act as if he or she is sad or in low spirits? Does he or she cry? yes or no mild, moderate or severe Does the patient become upset when separated from you? Does he or she have any other signs of nervousness, such as shortness of breath, sighing, being unable to relax, or feeling excessively tense? yes or no mild, moderate or severe Does the patient appear to feel too good or act excessively happy? yes or no mild, moderate or severe Does the patient seem less interested in his or her usual activities and in the activities and plans of others? yes or no mild, moderate or severe Does the patient seem to act impulsively? For example, does the patient talk to strangers as if he or she knows them, or does the patient say things that might hurt other people s feelings? if yes is the behavior: mild, moderate or severe yes or no Is the patient impatient and cranky? Does he or she have difficulty coping with delays or waiting for planned activities? yes or no mild, moderate or severe Does the patient engage in repetitive activities, such as pacing around the house, handling buttons, wrapping string, or doing other things repeatedly? yes or no mild, moderate or severe Does the patient awaken you during the night, rise too early in the morning, or take excessive naps during the day? yes or no mild, moderate or severe Has the patient lost or gained weight, or had a change in the food he or she likes? yes or no mild, moderate or severe How much do the above behaviors marked yes bother you? Are they difficult to cope with? Please explain below

8 QUESTIONS ABOUT DRIVING Does he/she currently drive a vehicle? Yes No Unknown If No: is this due to memory or thinking problems? Yes No Unknown If Yes: have there been unexplained dents to his/her vehicle? Yes No Unknown Can he/she find his/her way about familiar streets? Yes No Unknown If currently driving, have you heard or expressed these complaints about his/her driving? Driving too slowly Yes No Unknown Driving too fast for conditions Yes No Unknown Doesn t observe signs or signals Yes No Unknown Difficulty predicting changes in traffic flow Yes No Unknown Failure to yield Yes No Unknown Easily frustrated or confused Yes No Unknown Frequently gets lost Yes No Unknown Takes the scenic route instead of a direct route Yes No Unknown Need instructions from passengers Yes No Unknown Poor road position (crossing over lines, driving on shoulder) Yes No Unknown Driving the wrong way on one way streets Yes No Unknown Would you be a passenger in the car or would you allow your children or grandchildren to ride with him/her? Yes No Unknown Please list any other information that you feel might be useful to us to better understand the patient, such as describing an average day, family dynamics, etc.: