Follow-up questionnaires
6-monthly memory assessment and review
This review is for patients who have started or are continuing memory medication. Please fill in these questionnaires before your 6-month review appointment. They tell me what has changed since your last appointment.
Why it matters
What the review looks at
The review looks at whether the medication is helping, any side effects, and changes in memory, daily function, mood, behaviour, safety, driving and carer stress.
It is not just about memory test scores. Stability, daily function, how well the medication is tolerated and carers’ observations are just as important when deciding whether treatment should continue.
A relative, family member or carer should complete the carer forms wherever possible, as they may notice changes the patient does not.
What you need to do
- The patient fills in the patient forms.
- A relative, family member or carer fills in the relative or carer forms.
- Please complete them at least 24 hours before your appointment, where possible.
- If you can, have the current medication list, a recent pulse (heart rate), weight and any recent medical letters to hand.
- Answers are saved only when you press Submit, so allow time to finish each form in one sitting.
For the patient
Patient forms
These are usually completed by the patient, with help if needed.
Medication Side-Effect Checklist
Possible side effects such as nausea, diarrhoea, dizziness, poor sleep, vivid dreams, weight loss, slow pulse, fainting or falls. 3–4 minutes.
Open the questionnaireDriving and Safety Review
Driving, DVLA, getting lost, accidents or near misses, family concerns and safety at home. 2–3 minutes.
Open the questionnaireMood and Wellbeing (GDS-15)
A short questionnaire about mood. 3–4 minutes.
Open the questionnaireWorry and Anxiety (GAI-20)
A short questionnaire about anxiety and worry. 3–4 minutes.
Open the questionnaire
For a relative or carer
Relative or carer forms
These are best completed by someone who knows the patient well.
Medication Benefit Review
The memory medication, dose, how regularly it is taken, any benefit, and whether you would like it to continue. 3–5 minutes.
Open the questionnaireFunction and Independence (BADLS)
Day-to-day function and practical abilities. 3–4 minutes.
Open the questionnaireBehaviour and Mood Changes (NPI-Q)
Changes in behaviour and mood, and how distressing they are for you. 4–5 minutes.
Open the questionnaireCarer Global Impression of Change (CGIC)
A brief overall judgement: better, the same or worse than 6 months ago.
Open the questionnaire
Only if asked
Forms Dr Jha may ask you to complete
Please fill these in only if Dr Jha has asked you to.
Depression and Anxiety (PHQ-9 and GAD-7)
For the patient. Sixteen questions about mood and worry over the last 2 weeks. About 5 minutes.
Open the questionnaireCarer Questionnaire (Zarit Burden Interview)
For the relative or carer. How caring affects you, so we can plan support. 5–10 minutes.
Open the questionnaire
Before you begin
- There are no right or wrong answers.
- Please answer honestly, based on the last 6 months.
- A family member can help with the online forms if needed.
- Patient forms should reflect the patient’s own feelings.
- Carer forms should reflect the carer’s own observations.
- It helps to have the current medication list, and a recent weight, pulse and blood pressure if you have them.
If you cannot complete the forms
Please still come to your appointment. We can go through the questionnaires together during the consultation if needed.
Your answers are stored securely on this website for Dr Jha, copied into your clinical record and deleted from the website within 90 days. Privacy notice