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503-228-CARE (2273)

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Studies
Resources
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Memory Loss New Patient Paperwork

Lorem Ipsum

View Open Positions

Date

PATIENT INFORMATION

Last Name *

First Name *

Middle Initial

Address

City

State/Province

Zip/Postal

Home Telephone *

Email Address *

Date of Birth

Sex

Age

Primary Physician Name

Clinic Name

Telephone Number

Physician Address

City

State

Zip

Employer

Occupation

Work Telephone Number

STUDY PARTNER INFORMATION

Name

Telephone Number (if different from patient)

Address

Employer

Occupation

Work Telephone Number

EMERGENCY CONTACT INFORMATION FOR PATIENT

Name

Relationship

Daytime Telephone Number

Address

Evening Telephone Number

PATIENT AUTOBIOGRAPHY

Date

Name (person with memory concerns):

Age

Date of birth

Potential study partner (spouse/partner/child/friend):

Contact Information: (cell)

Email

Primary cognitive (memory) complaints:

When did the cognitive (memory) complaints start?

Did they start GRADUALLY or SUDDENLY?

GRADUALLY

SUDDENLY

Are they getting WORSE or staying the SAME?

WORSE

SAME

How do cognitive (memory) issues affect your (your loved one’s) ability to function in life?

Has a health care professional evaluated the cognitive (memory) problems (circle)?

Yes

No

If so, has a diagnosis been made or treatment initiated? Diagnosis

Treatment?

Family history of memory loss

Yes

No

Who?

Diagnosis?

Current Habits:

Caffeine

Smoking

Alcohol

Substances

Education

Less HS

HS

Some college

College Grad

Grad School

Highest Degree

Primary occupation:

Retired

Yes

No

Current living situation

Alone

Domestic partner

Other

Major sources of stress?:

Person completing this form:

Thank you for your time
For staff use only: Date reviewed with clinician:___________________________
All entries in __________ink made by _______________upon review with the patient

Please check yes or no for each condition listed below

Cardiovascular

Pacemaker

Yes

No

Description / Comment

Start Date

Stop Date

High Blood Pressure

Yes

No

Atrial Fibrillation

Yes

No

High Cholesterol

Yes

No

Congestive Heart Failure

Yes

No

Heart Attack

Yes

No

Open Heart Surgery

Yes

No

Other:

Yes

No

Other:

Yes

No

Dermatological

Skin Problems

Yes

No

Psoriasis

Yes

No

Other:

Yes

No

Ears, nose, throat

Ear

Yes

No

Nose

Yes

No

Throat

Yes

No

Hearing Problems

Yes

No

Dentures

Yes

No

Other:

Yes

No

Endocrine

Diabetes

Yes

No

Thyroid Disease / Goiter

Yes

No

Other:

Yes

No

Eyes

Eye Disease

Yes

No

Glasses

Yes

No

Cataracts

Yes

No

Glaucoma

Yes

No

Other:

Yes

No

Gastrointestinal

Ulcers, Hernias

Yes

No

Liver / Gallbladder problems

Yes

No

Acid reflux / GERD

Yes

No

Constipation

Yes

No

Loose Stools

Yes

No

Hepatitis

Yes

No

Other:

Yes

No

Genito-urinary

Menstrual problems

Yes

No

Uterine / Ovarian/ Cervical Disease

Yes

No

Prostate Disease

Yes

No

Urinary Tract Infections

Yes

No

Urinary urgency or frequency

Yes

No

Bladder problems

Yes

No

Kidney problems

Yes

No

Other

Yes

No

Hematological

Blood Disease

Yes

No

Anemia

Yes

No

Other:

Yes

No

Musculoskeletal

Arthritis

Yes

No

Osteoporosis

Yes

No

Tendonitis

Yes

No

Trouble walking or standing (history of falls or fractures

Yes

No

Back pain

Yes

No

Other

Yes

No

Neoplastic

Cancer or Tumors

Yes

No

Other:

Yes

No

Neurological

Epilepsy / Seizures

Yes

No

Family History of Memory Loss

Yes

No

Neurological Disease

Yes

No

Stroke or TIA

Yes

No

Psychological

Depression

Yes

No

Agitation

Yes

No

Hallucinations

Yes

No

Delusions

Yes

No

Other:

Yes

No

Respiratory

Lung Disease

Yes

No

Cough

Yes

No

COPD/Emphysema

Yes

No

Other:

Yes

No

Allergies

Hay fever

Yes

No

Medications

Yes

No

Other

Yes

No

Other

Yes

No

Other

Headaches

Yes

No

Dizziness

Yes

No

Ringing in Ears

Yes

No

Medications:
What have you taken in the last 3 months?

Prescription Medication

None

Name

Dose

# Times / Day

Reason

Start Date

End Date

Supplements/Herbal Remedies

None

Name

Dose

# Times / Day

Reason

Start Date

Stop Date

Medications (prescription/supplements/over-the-counter) Taken Occasionally:

None

Name

Dose

# Times / Day

Reason

Start Date

Stop Date

Research Physician Review of Medical History:

Physician Signature:

Date

If you are human, leave this field blank.

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Memory Loss New Patient Paperwork

PATIENT INFORMATION

STUDY PARTNER INFORMATION

EMERGENCY CONTACT INFORMATION FOR PATIENT

PATIENT AUTOBIOGRAPHY

Please check yes or no for each condition listed below

Medications: What have you taken in the last 3 months?

Medications:
What have you taken in the last 3 months?