Sheffield Memory Service & Complex Geriatric Care

Specialist in Memory, Parkinson’s disease, Stroke, Dizziness, Falls & Complex Ageing

Sheffield Memory Service &
Complex Geriatric Care

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Sheffield Memory Service & Complex Geriatric Care

Specialist in Memory, Parkinson’s disease, Stroke, Dizziness, Falls & Complex Ageing

Memory Assessment Questionnaire

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- Step 1 of 10

Please 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 details

Please provide basic information about the patient and contact details.
This helps us prepare your consultation and communicate with you if needed.

Full name *

Past of of

Date of birth *

Address *

NHS number (if known)

Phone *

Email *

GP name & Surgery details *

Next of kin (to share cinic letter/invoice) *

Who is completing this questionnaire? *

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2. Personal & Social information

You are currently on Step 2 of 10.

Living status *

on her own
with partner
with son/daughter
care home
Other

Education level *

Primary school
Secondry school
College
University

Marital status *

Single
Married/Partner
Widow/Widower

Previous job and retired at age

Current smoker *

Alcohol intake *

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3. Symptom Timeline

This section asks when memory or thinking changes were first noticed and how they have progressed over time.
You are currently on Step 3 of 10.

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 years

How have symptoms changed? *

Gradually worsening
Sudden onset
Fluctuating
Stable

Compared with five years ago, memory is:

Much worse
Slightly worse
About the same
Better
Not sure

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4. Recent Changes in Alertness or Confusion

These questions help identify sudden or fluctuating confusion that may indicate an acute medical condition.
You are currently on Step 4 of 10.

Did confusion or memory problems start suddenly over a few days? *

Do symptoms vary during the day (sometimes better, sometimes worse)? *

Has the patient been unusually sleepy or difficult to wake? *

Did the confusion begin after a recent illness, infection, or hospital stay? *

Did symptoms begin after starting or changing medication? *

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5. Neurological Warning Symptoms

The following symptoms may indicate neurological conditions that require urgent medical attention. Please indicate if any of these have occurred.
You are currently on Step 5 of 10.

Did the memory or thinking problem start suddenly? *

Have symptoms worsened dramatically over the past 3 months? *

New severe or persistent headache? *

Any seizures or episodes of loss of consciousness? *

Weakness or numbness affecting one side of the body? *

New difficulty with speaking or understanding speech? *

Persistent double vision or major visual disturbance? *

New difficulty with walking or unsteadiness? *

New urinary urgency or incontinence with walking difficulty? *

Marked personality or behaviour change developing quickly? *

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6. Memory and Thinking Symptoms

These questions help us understand changes in memory and thinking.
You are currently on Step 6 of 10.

Memory problems *

Forgetting conversations
Repeating questions
Misplacing objects
Forgetting appointments
Difficulty remembering names

Thinking problems *

Difficulty planning tasks
Difficulty concentrating
Difficulty making decisions

Difficulty finding words Difficulty understanding conversations *

Difficulty finding words
Difficulty understanding conversations

Orientation *

Confusion about dates
Getting lost in familiar places

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7. Sleep screen

You are currently on Step 7 of 10.

Does the patient act out dreams (shouting, kicking)? *

2. Any vivid dreams or nightmares? *

3. Daytime sleepiness? *

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8. Daily Behaviour

These questions help us understand whether memory or thinking changes are affecting everyday activities and behaviour.
You are currently on Step 8 of 10.

Behavioural symptoms *

Depression or low mood
Anxiety
Irritability or agitation
Reduced motivation (apathy)
Sleep disturbance
Personality change
Fluctuation in alertness during the day

Has the patient seen things that are not really there, such as people, animals, or objects that others cannot see? *

Falls in past year *

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9. Medical History

You are currently on Step 9 of 10.

Past Medical history *

Stroke / TIA
Parkinson's disease
Heart disease
High blood pressure
Diabetes
Head injury
Depression

Current medications (list here) *

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10. Safety and Additional Information

This final section helps identify any safety concerns and allows you to upload relevant medical documents.

Safety concerns *

Wandering
Medication errors
Leaving appliances on
Driving concerns

You are almost finished. Please upload any file(s) and click Submit.

Consent *

I confirm that the information provided is accurate to the best of my knowledge.
I consent to this information being used for clinical assessment and stored securely in accordance with data protection regulations.

Upload any letter, results etc

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

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Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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