Pre-consultation Assessment Memory Assessment Pre-Consultation QuestionnairePre-Consultation Memory Assessment QuestionnairePlease complete this form before the consultation. It helps me understand memory symptoms, day-to-day function, health background, and any concerns from family or carers. If possible, the form should be completed with input from someone who knows the patient well. There are no right or wrong answers. Please answer as fully and honestly as possible. It usually takes about 15-20 minutes and can be completed at your own pace.1. Patient detailsPlease provide basic information about the patient and contact details.This helps us prepare your consultation and communicate with you if needed.First NameLast NameDate of birthNHS number (if known)AddressAddress Line 1Address Line 2CityZip CodeEmail addressGP detailsWho is completing this questionnaire?- Select -PatientFamily memberCarerOtherPersonal informationLiving status On her own With partner With son/daughter Care home OtherEducation level Primary school Secondry school College UniversityMarital status Single Partner/married Widow/widower2. Symptom TimelineThis section asks when memory or thinking changes were first noticed and how they have progressed over time. You are currently on Step 2 of 8. What is the main reason for this consultation?When were symptoms first noticed? Less than 6 months 6–12 months 1-2 years more than 2 yearsHow have symptoms changed? Gradually worsening Sudden onset Fluctuating StableCompared with five years ago, memory is: Much worse Slightly worse About the same Better Not sure3. Recent Changes in Alertness or ConfusionThese questions help identify sudden or fluctuating confusion that may indicate an acute medical condition. You are currently on Step 3 of 8. Did confusion or memory problems start suddenly over a few days? Yes NoDo symptoms vary during the day (sometimes better, sometimes worse)? Yes NoHas the patient been unusually sleepy or difficult to wake? Yes NoDid the confusion begin after a recent illness, infection, or hospital stay? Yes NoDid symptoms begin after starting or changing medication? Yes No4. Neurological Warning SymptomsThe following symptoms may indicate neurological conditions that require urgent medical attention. Please indicate if any of these have occurred. You are currently on Step 4 of 8. Did the memory or thinking problem start suddenly? Yes NoHave symptoms worsened dramatically over the past 3 months? Yes NoNew severe or persistent headache? Yes NoAny seizures or episodes of loss of consciousness? Yes NoWeakness or numbness affecting one side of the body? Yes NoNew difficulty speaking or understanding speech? Yes NoPersistent double vision or major visual disturbance? Yes NoNew difficulty walking or unsteadiness? Yes NoNew urinary urgency or incontinence with walking difficulty? Yes NoMarked personality or behaviour change developing quickly? Yes No5. Memory and Thinking SymptomsThese questions help us understand changes in memory and thinking. You are currently on Step 5 of 8. Memory problems Forgetting conversations Repeating questions Misplacing objects Forgetting appointments Difficulty remembering namesThinking problems Difficulty planning tasks Difficulty concentrating Difficulty making decisionsLanguage Difficulty finding words Difficulty understanding conversationsOrientation Confusion about dates Getting lost in familiar places6. Daily BehaviourThese questions help us understand whether memory or thinking changes are affecting everyday activities and behaviour. You are currently on Step 6 of 8. Behavioural symptoms Depression or low mood Anxiety Irritability or agitation Reduced motivation (apathy) Sleep disturbance Personality change Fluctuation in alertness during the dayHas the patient seen things that are not really there, such as people, animals, or objects that others cannot see? Yes NoFalls in past year None One fall More than one fall7. Medical History Please provide information about medical conditions, alcohol intake, and medications that may affect memory or overall health. You are currently on Step 7 of 8. Past Medical history Stroke / TIA Parkinson's disease Heart disease High blood pressure Diabetes Head injury DepressionAlcohol intake None Occasional Weekly DailyPlease list current medications8. Safety and Additional Information This final section helps identify any safety concerns and allows you to upload relevant medical documents. You are currently on Step 8 of 8. Safety concerns Wandering Medication errors Leaving appliances on Driving concerns You are almost finished. Please review your answers, upload any file(s) and click Submit. I confirm the information provided is accurate. I confirm that the information given is accurate to the best of my knowledge. I consent to this information being reviewed as part of the pre-consultation assessment. If I am completing this as an informant or carer, I confirm I have the patient’s knowledge or it is in their best interests for this information to be shared.Signature/Typed name Together We Can Do More Spire Claremont Hospital 0114 263 0330 Circle Thornbury Hospital 0114 266 1133
