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.

Please enable JavaScript in your browser to complete this form.

- 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

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? *

life of Day-to-day

Have you experienced any side effects or concerns? *

Submit

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

Back to the 6-monthly review questionnaires