Medication Benefit Review

This form is for your appointment with Dr Jha. It is not checked out of hours, so please don’t use it for anything urgent: call 999 in an emergency, or NHS 111 or your GP for other urgent problems.

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- Step 1 of 4

These medications often work by slowing decline rather than producing obvious improvement. A response of "no change" may itself represent a good outcome in a progressive condition.

Please answer based on the period since treatment was started.

1. Informant details

Full name *

First

Last

Phone *

Email *

Relationship with the patient *--- Select Choice ---PartnerRelativecarer

2. Patient details

Full name *

Date of birth *

Next

3. Medication adherence

Medication and current dose *

• Donepezil 5mg
• Donepezil 10mg
• Rivastigmine patch 4.2mg/24hr patch
• Rivastigmine patch 9.5mg/24hr
• Memantine 5mg OD
• Memantine 10mg OD
• Memantine 20mg OD
• NONE

In the past month, how often were doses missed? *

• Never
• Occasionally (1-3 times/week)
• Weekly
• Frequently

Next

4. Perceived benefit

Since starting the medication, compared with before treatment:

1. Overall memory *

• Much better
• Slightly better
• No change
• Slightly worse
• Much worse

2. Attention and concentration *

• Much better
• Slightly better
• No change
• Slightly worse
• Much worse

3. Ability to hold a conversation *

• Much better
• Slightly better
• No change
• Slightly worse
• Much worse

7. to concentration

4. Day-to-day functioning (managing everyday activities) *

• Much better
• Slightly better
• No change
• Slightly worse
• Much worse

5. Mood and motivation *

• Much better
• Slightly better
• No change
• Slightly worse
• Much worse

6. Behaviour (less agitation, anxiety or irritability) *

• Much better
• Slightly better
• No change
• Slightly worse
• Much worse

7. Sleep *

• Much better
• Slightly better
• No change
• Slightly worse
• Much worse

8. Overall quality of life *

• Much better
• Slightly better
• No change
• Slightly worse
• Much worse

Next

5. Overall impression

9. Overall impression of the medication *

• Very helpful
• Somewhat helpful
• No noticeable benefit
• Unsure

10. Would you wish to continue this medication? *

• Yes
• No
• Unsure

Comments

What improvements, if any, have you noticed since starting the medication? *

Have you experienced any side effects or concerns? *

Submit

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Back to the 6-monthly review questionnaires