PATIENT INFORMATION





Address











STUDY PARTNER INFORMATION





EMERGENCY CONTACT INFORMATION FOR PATIENT



 

PATIENT AUTOBIOGRAPHY










Did they start GRADUALLY or SUDDENLY?

Are they getting WORSE or staying the SAME?


Has a health care professional evaluated the cognitive (memory) problems (circle)?

If so, has a diagnosis been made or treatment initiated?


Family history of memory loss

Current Habits:



Education


Retired

Current living situation



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
High Blood Pressure
Atrial Fibrillation
High Cholesterol
Congestive Heart Failure
Heart Attack
Open Heart Surgery
Other:
Other:
Dermatological
Skin Problems
Psoriasis
Other:
Ears, nose, throat
Ear
Nose
Throat
Hearing Problems
Dentures
Other:
Endocrine
Diabetes
Thyroid Disease / Goiter
Other:
Eyes
Eye Disease
Glasses
Cataracts
Glaucoma
Other:
Gastrointestinal
Ulcers, Hernias
Liver / Gallbladder problems
Acid reflux / GERD
Constipation
Loose Stools
Hepatitis
Other:
Genito-urinary
Menstrual problems
Uterine / Ovarian/ Cervical Disease
Prostate Disease
Urinary Tract Infections
Urinary urgency or frequency
Bladder problems
Kidney problems
Other
Hematological
Blood Disease
Anemia
Other:
Musculoskeletal
Arthritis
Osteoporosis
Tendonitis
Trouble walking or standing (history of falls or fractures
Back pain
Other
Neoplastic
Cancer or Tumors
Other:
Neurological
Epilepsy / Seizures
Family History of Memory Loss
Neurological Disease
Stroke or TIA
Psychological
Depression
Agitation
Hallucinations
Delusions
Other:
Respiratory
Lung Disease
Cough
COPD/Emphysema
Other:
Allergies
Hay fever
Medications
Other
Other
Other
Headaches
Dizziness
Ringing in Ears

For Staff Use Only

Description / Comment

Start Date

Stop Date

Medications:
What have you taken in the last 3 months?

Prescription Medication
Supplements/Herbal Remedies
Medications (prescription/supplements/over-the-counter) Taken Occasionally: