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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
WhatsApp 07873 258818 Contact us Book an appointment
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Before your memory assessment

Pre-consultation questionnaires

To make your consultation as focused and useful as possible, please fill in the questionnaires below online before your appointment. They tell me about memory changes, mood, anxiety and day-to-day function, so we can use the appointment for assessment, explanation and planning.

How it works

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.
  • Answers are saved only when you press Submit, so allow time to finish each form in one sitting.
  • If you can’t complete a form online, print it, fill it in by hand and bring it to your appointment.

For the patient

Patient forms

These forms should usually be completed by the patient. A relative may help with the online form.

  • Memory Assessment Questionnaire

    Memory symptoms, daily life, health background and family concerns. About 15–20 minutes.

    Open the questionnaire

  • Mood and Wellbeing (GDS-15)

    Fifteen yes-or-no questions about mood. 3–5 minutes.

    Open the questionnaire

  • Worry and Anxiety (GAI-20)

    Twenty agree-or-disagree statements about worry. 3–5 minutes.

    Open the questionnaire

For a relative or carer

Relative or carer forms

These forms are best completed by a relative, family member or carer who knows the patient well.

  • Recent Memory and Thinking Changes (AD-8)

    Eight questions about recent changes. A couple of minutes.

    Open the questionnaire

  • Long-Term Memory and Thinking Changes (IQCODE)

    Compares memory and thinking now with 10 years ago.

    Open the questionnaire

  • Daily Function and Independence (BADLS)

    Twenty questions about everyday abilities. Under 10 minutes.

    Open the questionnaire

  • Behaviour and Mood Changes (NPI-Q)

    Changes in behaviour and mood, and how they affect you. 5–6 minutes.

    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 questionnaire

  • Carer 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 how things are now.
  • If help is needed with the online form, a relative may assist.
  • Patient forms should reflect the patient’s own feelings.
  • Carer forms should reflect the carer’s own observations.

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