Date
PATIENT INFORMATION
Last Name
First Name
Middle Initial
Address
City
State
Zip/Postal
Home Telephone
Email Address
Date of Birth
Sex
Age
Primary Physician Name
Clinic Name
Telephone Number
Physician Address
City
State
Zip
Employer
Occupation
Work Telephone Number
STUDY PARTNER INFORMATION
Name
Telephone Number (if different from patient)
Address (if different from patient)
Employer
Occupation
Work Telephone Number
EMERGENCY CONTACT INFORMATION FOR PATIENT
Name
Relationship
Daytime Telephone Number
Address
Evening Telephone Number
PATIENT AUTOBIOGRAPHY
Date
Name (person with memory concerns):
Age
Date of birth:
Potential study partner (spouse/partner/child/friend):
Contact Information: (cell)
Email
Primary cognitive (memory) complaints:
When did the cognitive (memory) complaints start?
Did they start GRADUALLY or SUDDENLY?
GRADUALLY
SUDDENLY
Are they getting WORSE or staying the SAME?
WORSE
SAME
How do cognitive (memory) issues affect your (your loved one's) ability to function in life?
Has a health care professional evaluated the cognitive (memory) problems (circle)?
Yes
No
If so, has a diagnosis been made or treatment initiated?
Diagnosis
Treatment?
Family history of memory loss
Yes
No
Who?
Diagnosis?
Current Habits:
Caffeine
Smoking
Alcohol
Substances
Education
Less HS
HS
Some college
College Grad
Grad School
Highest Degree
Primary occupation:
Retired
Yes
No
Current living situation
Alone
Domestic partner
Other
Major sources of stress?:
Person completing this form:
Thank you for your time
For staff use only: Date reviewed with clinician:___________________________
All entries in __________ink made by _______________upon review with the patient
Please check yes or no for each condition listed below
Cardiovascular
Pacemaker
Yes
No
High Blood Pressure
Yes
No
Atrial Fibrillation
Yes
No
High Cholesterol
Yes
No
Congestive Heart Failure
Yes
No
Heart Attack
Yes
No
Open Heart Surgery
Yes
No
Other:
Yes
No
Other:
Yes
No
Dermatological
Skin Problems
Yes
No
Psoriasis
Yes
No
Other:
Yes
No
Ears, nose, throat
Ear
Yes
No
Nose
Yes
No
Throat
Yes
No
Hearing Problems
Yes
No
Dentures
Yes
No
Other:
Yes
No
Endocrine
Diabetes
Yes
No
Thyroid Disease / Goiter
Yes
No
Other:
Yes
No
Eyes
Eye Disease
Yes
No
Glasses
Yes
No
Cataracts
Yes
No
Glaucoma
Yes
No
Other:
Yes
No
Gastrointestinal
Ulcers, Hernias
Yes
No
Liver / Gallbladder problems
Yes
No
Acid reflux / GERD
Yes
No
Constipation
Yes
No
Loose Stools
Yes
No
Hepatitis
Yes
No
Other:
Yes
No
Genito-urinary
Menstrual problems
Yes
No
Uterine / Ovarian/ Cervical Disease
Yes
No
Prostate Disease
Yes
No
Urinary Tract Infections
Yes
No
Urinary urgency or frequency
Yes
No
Bladder problems
Yes
No
Kidney problems
Yes
No
Other
Yes
No
Hematological
Blood Disease
Yes
No
Anemia
Yes
No
Other:
Yes
No
Musculoskeletal
Arthritis
Yes
No
Osteoporosis
Yes
No
Tendonitis
Yes
No
Trouble walking or standing (history of falls or fractures
Yes
No
Back pain
Yes
No
Other
Yes
No
Neoplastic
Cancer or Tumors
Yes
No
Other:
Yes
No
Neurological
Epilepsy / Seizures
Yes
No
Family History of Memory Loss
Yes
No
Neurological Disease
Yes
No
Stroke or TIA
Yes
No
Psychological
Depression
Yes
No
Agitation
Yes
No
Hallucinations
Yes
No
Delusions
Yes
No
Other:
Yes
No
Respiratory
Lung Disease
Yes
No
Cough
Yes
No
COPD/Emphysema
Yes
No
Other:
Yes
No
Allergies
Hay fever
Yes
No
Medications
Yes
No
Other
Yes
No
Other
Yes
No
Other
Headaches
Yes
No
Dizziness
Yes
No
Ringing in Ears
Yes
No
For Staff Use Only
Description / Comment
Start Date
Stop Date
Medications:
What have you taken in the last 3 months?
Prescription Medication
None
Name
Dose
# Times / Day
Reason
Start Date
Stop Date
Supplements/Herbal Remedies
None
Name
Dose
# Times / Day
Reason
Start Date
Stop Date
Medications (prescription/supplements/over-the-counter) Taken Occasionally:
None
Name
Dose
# Times / Day
Reason
Start Date
Stop Date
Research Physician Review of Medical History:
Physician Signature:
Date
Submit
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