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Private, consultant-led clinic. Not part of the NHS memory service. No GP referral needed.

Sheffield Memory Service & Geriatric Care Dr Pravin Jha · Consultant Geriatrician & Memory Specialist
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Relative or carer questionnaire

Long-Term Memory and Thinking Changes Questionnaire (IQCODE)

For a family member or carer who has known the patient for several years. Sixteen questions on whether everyday memory and thinking are better, worse or about the same as around 10 years ago.

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.

Please think about how this person was 10 years ago and compare it with how they are now.

For each situation, choose whether it has improved, stayed the same or got worse over the past 10 years. Compare with how the person was 10 years ago, not with what is normal for their age.

About you

Your relationship to the patient

About the person you care for

Questions

1. Remembering things about family and friends, e.g. occupations, birthdays, addresses
Leave unanswered if you cannot judge this activity; do not guess.
2. Remembering things that have happened recently
Leave unanswered if you cannot judge this activity; do not guess.
3. Recalling conversations a few days later
Leave unanswered if you cannot judge this activity; do not guess.
4. Remembering his/her address and telephone number
Leave unanswered if you cannot judge this activity; do not guess.
5. Remembering what day and month it is
Leave unanswered if you cannot judge this activity; do not guess.
6. Remembering where things are usually kept
Leave unanswered if you cannot judge this activity; do not guess.
7. Remembering where to find things which have been put in a different place from usual
Leave unanswered if you cannot judge this activity; do not guess.
8. Knowing how to work familiar machines around the house
Leave unanswered if you cannot judge this activity; do not guess.
9. Learning to use a new gadget or machine around the house
Leave unanswered if you cannot judge this activity; do not guess.
10. Learning new things in general
Leave unanswered if you cannot judge this activity; do not guess.
11. Following a story in a book or on TV
Leave unanswered if you cannot judge this activity; do not guess.
12. Making decisions on everyday matters
Leave unanswered if you cannot judge this activity; do not guess.
13. Handling money for shopping
Leave unanswered if you cannot judge this activity; do not guess.
14. Handling financial matters, e.g. the pension, dealing with the bank
Leave unanswered if you cannot judge this activity; do not guess.
15. Handling other everyday arithmetic problems, e.g. knowing how much food to buy, knowing how long between visits from family or friends
Leave unanswered if you cannot judge this activity; do not guess.
16. Using his/her intelligence to understand what's going on and to reason things through
Leave unanswered if you cannot judge this activity; do not guess.
Consent

Your answers are stored securely on this website for Dr Jha. They are copied into your clinical record and deleted from the website within 90 days. Privacy notice

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