Pre-Visit Questionnaire

Name: _______________________

MR#: ________________________

Imprint Area

Center for Memory Care

This questionnaire is to be filled out by someone who knows you well.Name of Person completing this form: ________________________ Relationship to Patient: _____________How often do you see the patient?: ____________________________________ Telephone: (___) ___-____

Thank you for having this form completed before your visit. It will allow your doctor to perform the most complete evaluation possible when you arrive for your appointment. Your time and effort is much appreciated.

Referral DataWhat is (are) the main reason(s) for bringing the patient to the center? (check all that apply):

Suspected Alzheimer’s disease or other dementiaSecond opinion on pre-existing AD or other dementiaOther: __________________________________________

Neuropsychological SymptomsMemory1. How long ago were memory problems first noted? __________ years, _____________ months ago2. What did you first notice or what concerned you? _____________________________________________

____________________________________________________________________________________3. Changes in memory were: Gradual Abrupt4. Over the last 6 months, memory is: Worsening Staying the same Getting better

In the last 3 months, have you noticed any of the following? Frequently Sometimes Does not Apply

Problems with recent memoryDifficulty remembering a short list of items, e.g. shopping listRepeating statements, questions, or storiesTend to live in the pastMisplaced, lost or hidden objectsGetting lost around the neighborhood

Missed appointments or shown up on the wrong day/timeDifficulty remembering to take medicationsDecreased recognition of family or close friendsProblems remembering important events or occasionsBurned pots or pans on the stoveDifficulty learning how to use a tool or gadget

Comments ________________________________________________________________________________________ ________________________________________________________________________________________

Language/Speech1. How long ago were language or speech problems first noted? __________ years, __________ months ago2. What did you first notice or what concerned you? _____________________________________________

____________________________________________________________________________________3. Changes in language were: Gradual Abrupt4. Since the problems began, they are: Worsening Staying the same Getting better

In the last 3 months, have you noticed any of the following? Frequently Sometimes Does not Apply

Difficulty recalling wordsUsing the wrong wordFrequently describing an object rather than stating what it isDifficulty following or understanding conversationPauses or hesitation in speech

Judgment/Reasoning1. How long ago were judgement or reasoning problems first noted? _______ years, _________ months ago2. What did you first notice or what concerned you? _____________________________________________

____________________________________________________________________________________3. Changes in judgment or reasoning were: Gradual Abrupt4. Since the problems began, they are: Worsening Staying the same Getting better

In the last 3 months, have you noticed any of the following? Frequently Sometimes Does not Apply

Less clear or less sharp than beforeProblem reading written materials and discussing contentsRecognizing an emergency situation and acting appropriately, e.g. small fire in the kitchenProblems with decision making

Comments ________________________________________________________________________________________ ________________________________________________________________________________________

Comments ________________________________________________________________________________________ ________________________________________________________________________________________

Assessment of Stressors

Have any of the following occurred during the past year? Yes No

Change in living situationChange in financial situationMarriageChange in health of family member

Mood/Personality/Behavior

In the last 1 month, have you noticed any of the following? Frequently Sometimes Does not Apply

Personality changeFeeling down, depressed or hopelessSocially withdrawnLess interest in doing things, hobbies or activitiesStaring off into spaceIrritable or easily frustrated

Rapid changes in moodStressed outMore stubborn, agitated, aggressive or resistive to helpActing impulsively without consideration of consequencesBelieving others are stealing from him/her or planning to harm him/herDelusions/false beliefs, i.e. believing that things that have happened haven’tHearing voices, seeing things, talking to people who are not thereFalling asleep, staying asleep or sleeping too muchFeeling anxious, nervous, tense or fearfulFollowing or “shadowing” caregiverHiding or hoarding thingsHyperactivity/restlessness, e.g. can’t sit still, paces, wrings handsInappropriate behavior in publicWandering

Comments ________________________________________________________________________________________ ________________________________________________________________________________________

Comments ________________________________________________________________________________________ ________________________________________________________________________________________

Functional Abilities

Task

Patient Needs Help? Totally Dependent Never Did

If help needed,

who helps?Needs NO assistance or supervision

Has difficulty but does by

self

Needs assistance or supervision

Cannot do at all Baseline

Feeding selfContinence (control bowel and bladder com-pletely)Getting to toiletGetting dressedBathing or showeringWalking across the room (includes using cane or walker)Writing checks, paying bills, or keeping financial recordsAssembling tax records, business affairs, or papersShopping alone for clothes, household ne-cessities, or groceriesPlaying a game of skill or working on a hobbyHeating water, making a cup of coffee, or turning off the stovePreparing a balanced mealKeeping track of current eventsPaying attention to, un-derstanding, or discuss-ing a TV program, book or magazineRemembering appoint-ments, family occasions, holidays or medicationsTraveling out of the neighborhood, driving, or arranging to take buses

Social Function

Activities/Interests

Select the activities in which the patient regularly participates: Shopping CookingExercise Card ClubGardening Dining Out Pets MusicDancing Travel

_____________________________________________________Church Others: Driving

Yes No, stopped driving No, never droveIs the patient driving at this time? If driving, do you have concerns about his/her driving? Yes No

If stopped driving, in what year did the patient stop driving? ___________ YesStill has driver’s license? No

Safety:

YesDoes patient own any firearms/hunting knives? No Are there firearms in the home? Yes No

Any history of wandering or getting lost while outside the home? NoYes ______________

Any history of falls? Yes No If yes, when was the last fall?

YesIs the patient afraid of falling? No Head Trauma:

YesAny history of head injury with loss of consciousness? NoIf yes, when? ___________________________

YesHas patient participated in any activities associated with likelihood of blows to the head? Noe.g. boxing, football, ice or roller hockey, soccer, baseball, basketball, and snow skiing Alcohol:

How much alcohol does the patient drink? _________ What type of alcohol (wine, vodka, etc.)? ___________

Past Psychiatric History DepressionBipolar Disorder Drug DependenceAnxiety

_________________________________________Schizophrenia Other psychiatric disorders: 1. Past psychiatric hospitalizations: __________________________________________________________2. Outpatient therapy: ____________________________________________________________________3. Prior psychiatric medications (and their indications): ___________________________________________

____________________________________________________________________________________ 4. ____________________________History of suicidal attempt? Yes No When?

5. History of abuse or trauma? Emotional Physical SexualComments: ______________________________________________________________________________6. Substance Use History (e.g. alcohol, marijuana, cocaine, etc.)

• Past substances used (more than 12 months ago): _________________________________________• Current substances used: _____________________________________________________________

Current MedicationsPlease review the medication list given to the patient and compare it to the medications that the patient actually takes at home. Make any corrections if needed. Please add any other medications, including herbal/alternative medications, multi-vitamins, or any other over-the-counter medications being taken:

Name Dosage How Often?

Family HistoryDoes the patient have any family members with any of the following conditions?

Condition Which Family Member? Age of Onset Dementia, Alzheimer’s Disease Heart Disease Stroke Parkinson’s Disease Depression Cancer

Other medical or psychiatric problems that run in the family: ________________________________________

Social HistoryCity/state and country where patient was born: __________________________________________________City/state and country where patient was raised: _________________________________________________Native Language: ______________________________ Needs an interpreter? Yes NoEducation

Less than 8th grade Some high school, grade level: ______ High school graduateSome college College graduate, Degree: ______________________ Graduate school, Degree: ________________________

Work Status

Retired, when? _______ Working part-time Working full-timeList principal occupation and other prior significant past occupations: _________________________________________________________________________________________________________________________

Marital Status

Never married Married; how many years? _____ SeparatedDivorced Widowed; how many years? _____ Living with significant other

How many children does the patient have? _______Are they in regular contact with the patient? Yes No

Living Arrangements

Single-family house Condo Apartment Board and care/assisted living: _________________ Nursing homeOther (specify): _______________________

How many years at present location? _______________

Check any of the following individuals that are living in the home with the patient:Spouse/Partner Son Son-in-law DaughterDaughter-in-law Other relatives Friend Other: ____________

Is there someone helping the patient in the home? Yes NoIf yes, name and relationship to patient? ________________________________________How many hours per day and per week? _____ hours per day; _____ days per week

Is this sufficient to meet the patient needs? Yes No

Who should be called if patient is sick and needs help? Please check the name of the person who is designat-ed to be the health care representative or durable power of attorney for healthcare.

POA Name Relationship Phone Number(___) ____-_______(___) ____-_______(___) ____-_______

Do we have permission to speak to the person(s) listed above on the patient’s behalf? Yes No

Planning for Future Health Care

Does patient have a Health Care Representative/Durable Power of Attorney for Healthcare? Yes NoAdvanced Directives, POLST, or Living Will Completed? Yes NoIf yes, please submit a copy with this form.