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Memory questionnaire

Patient questionnaire

Memory Assessment Questionnaire

Please complete this before your memory assessment. It covers the memory or thinking problem, how it started, health background, family history and any previous tests. If possible, fill it in with someone who knows you well. It usually takes 15–20 minutes, and you can stop and come back to it.

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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Patient details - Step 1 of 10

Please complete this form before the consultation. It tells me about the memory or thinking problem, how it started, health background, family history and any previous tests. Separate short questionnaires cover mood, worry, day-to-day function and behaviour, so they are not repeated here.

If possible, complete it with someone who knows the patient well. There are no right or wrong answers. It takes about 15–20 minutes, and you can save it and come back later.

1. Patient details

Basic information about the patient, so we can prepare the consultation and contact you if needed.

Patient full name *

Date of birth *

For example 12/03/1941

Address *

NHS number (if known)

Phone *

Email *

GP name and surgery *

Next of kin: name, relationship and phone number *

We may share the clinic letter and invoice with them.

Who is completing this questionnaire? *

The patient
The patient, with help from family
Husband, wife or partner
Other relative
Carer
Other

Patient's first language *

English
Another language

Which language?

Is an interpreter needed for the appointment?

Does the patient know about this assessment and agree to it? *

Yes
Not sure
No

What would you most like from this assessment?

For example: a diagnosis, reassurance, treatment, advice on driving or support.

2. Background and lifestyle

Age when the patient left full-time education *

A number, for example 15 or 21. This is needed to interpret memory test scores.

Highest qualification

Left school without qualifications
School qualifications (e.g. O levels, CSEs, GCSEs)
A levels or equivalent
College, vocational or trade qualification
University degree
Postgraduate degree

Main job, and age at retirement

Dyslexia or other lifelong difficulty with reading, writing or learning

Yes
No
Not sure

Living situation *

Lives alone
With husband, wife or partner
With other family
Sheltered or extra-care housing
Care home
Other

Marital status

Single
Married or civil partnership
Living with partner
Divorced or separated
Widowed

Help at home at present

None
Family or friends
Paid carers
Day centre
Other

Hearing *

No difficulty
Some difficulty, no hearing aids
Uses hearing aids
Severe hearing loss

Please bring hearing aids to the appointment.

Eyesight *

No difficulty
Sees well with glasses
Difficulty even with glasses
Registered sight impaired

Please bring reading glasses to the appointment.

Smoking

Never smoked
Ex-smoker
Current smoker

Alcohol: usual units per week

None
1–7
8–14
15–21
22–35
More than 35
Not sure

A pint of beer or cider is about 2–3 units, a medium glass of wine about 2 units, a single measure of spirits 1 unit.

Has the patient ever drunk heavily for a long period (for example more than 35 units a week)?

Yes
No
Not sure

3. How it started

What is the main reason for this consultation? *

When was a problem first noticed? *

Less than 6 months ago
6–12 months ago
1–2 years ago
2–5 years ago
More than 5 years ago

What was the first change noticed? *

Forgetting recent events or conversations
Difficulty finding words or understanding speech
A change in personality or behaviour
Getting lost, misjudging distances or not recognising things
Slowness, tremor or difficulty walking
Low mood, worry or loss of interest
Not sure

Choose the one that came first, even if others followed.

Who noticed it first?

The patient
Husband, wife or partner
Other family or friends
GP or another professional
Not sure

How did it begin? *

Gradually, over months
Suddenly, over days or weeks
After an illness, operation, fall or bereavement
Not sure

Since then, has it been: *

Slowly getting worse
Worse in steps (sudden drops, then steady)
Up and down (good days and bad days)
About the same
Improving

Does the patient notice the problems themselves?

Yes, and is worried about them
Yes, but is not worried
Only sometimes
No

4. Recent changes and warning signs

Some causes of confusion need treatment quickly. If any of these started in the last few days, please contact your GP or NHS 111 now rather than waiting for the appointment.

Did the confusion or memory problem start suddenly, over a few days? *

Does it vary during the day (sometimes much better, sometimes much worse)? *

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

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

Did it begin after starting or changing a medicine? *

Other symptoms

Answer Yes to anything that is new.

Has it got much worse over the past 3 months? *

New severe or persistent headache *

Seizures (fits) or blackouts *

Weakness or numbness on one side of the body *

New difficulty speaking or understanding speech *

Persistent double vision or major change in vision *

New unsteadiness or difficulty walking *

New bladder urgency or incontinence, together with walking difficulty *

Marked change in personality or behaviour over weeks *

5. Thinking, language, seeing and movement

Tick anything that is new or worse than before. Memory and day-to-day activities are covered in the relative or carer questionnaires.

Thinking

Difficulty planning or organising
Difficulty concentrating
Slower thinking
Difficulty doing two things at once
None of these

Language

Difficulty finding words
Using the wrong word
Difficulty understanding what others say
Speech slower or more effortful
New difficulty reading, writing or spelling
None of these

Seeing and recognising

Misjudging distances, steps or kerbs
Difficulty recognising familiar faces
Difficulty recognising everyday objects
Getting lost in familiar places
Difficulty reading, even with glasses
Putting clothes on the wrong way round
None of these

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

Movement

Tremor (shaking)
Slower movements
Shuffling or smaller steps
Stiffness
Quieter voice
Smaller handwriting
None of these

Any falls in the past year? *

Other changes

Loss of sense of smell
Constipation
Dizziness or light-headedness on standing up
None of these

Changes in character noticed by others

Less concern for other people’s feelings
Rigid routines or repetitive habits
New liking for sweet foods, or overeating
Out-of-character spending or decisions
None of these

6. Sleep

Does the patient act out dreams (shouting, punching or kicking in sleep)? *

Vivid dreams or nightmares? *

Sleepy during the day? *

Loud snoring, or pauses in breathing during sleep?

Yes
No
Not known

7. Health and medicines

Medical conditions (tick all that apply)

Stroke or mini-stroke (TIA)
Heart attack or angina
Atrial fibrillation (irregular heartbeat)
Heart failure
High blood pressure
High cholesterol
Diabetes
Kidney disease
Thyroid disease
Low vitamin B12 or anaemia
Sleep apnoea
Epilepsy
Parkinson’s disease
Head injury with loss of consciousness
Depression
Anxiety
Bipolar disorder or psychosis
Cancer
Alcohol problems
None of these

Other medical conditions or operations

Weight loss without trying in the past year?

Yes
No
Not sure

Current medicines, with doses *

Include over-the-counter medicines, sleeping tablets, antihistamines, bladder and pain medicines, and supplements. You can upload a repeat prescription at the end.

Allergies to medicines

8. Family history

Has a parent, brother, sister or child had dementia or memory problems? *

Yes
No
Not known

35 of and

Who, the type of dementia if known, and the age it started

Other conditions in close family

Parkinson’s disease
Motor neurone disease
Huntington’s disease
Stroke before age 65
None of these
Not known

9. Previous tests, safety and plans

Has the patient had a memory assessment before?

No
Yes, at an NHS memory clinic
Yes, privately
Yes, a memory test at the GP
Not sure

When and where, and any results or scores

Brain scan in the past 5 years?

No
CT scan
MRI scan
Yes, not sure which
Not sure

When and where was the scan?

Blood tests in the past 6 months?

Yes
No
Not sure

If you have the results, please upload them at the end.

Does the patient drive at present?

Yes
No, has stopped
Has never driven

Safety concerns

Getting lost when out
Leaving the cooker, gas or taps on
Mistakes with medicines
Scams or unusual spending
Lives alone with little support
Concerns about driving
None of these

Lasting Power of Attorney for health and welfare

Yes, registered
In progress
No
Not sure

Lasting Power of Attorney for property and financial affairs

Yes, registered
In progress
No
Not sure

Advance decision to refuse treatment, or a ReSPECT form

Yes
No
Not sure

Anything else you would like Dr Jha to know?

10. Upload and submit

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

Upload letters, test results or a repeat prescription (optional)

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

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.

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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