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NEW PATIENT QUESTIONNAIRE PATIENT INFORMATION NAME (LAST, FIRST, MIDDLE) DATE: DATE OF BIRTH (REQUIRED) ADDRESS CITY STATE ZIP CODE HOME PHONE CELL PHONE SSN# EMAIL ADDRESS RELATIONSHIP STATUS PRIMARY LANGUAGE GENDER ETHNIC BACKGROUND: HISPANIC CAUCASIAN AFRICAN AMERICAN NATIVE AMERICAN ASIAN OTHER: PERSON COMPLETING QUESTIONNAIRE (IF DIFFERENT THAN ABOVE) NAME (LAST, FIRST, MIDDLE) RELATIONSHIP TO PATIENT ADDRESS CITY STATE ZIP CODE HOME PHONE CELL PHONE EMAIL ADDRESS YES NO DOES THE PATIENT HAVE A DURABLE HEALTH CARE POWER OF ATTORNEY YES NO DOES THE PATIENT HAVE A DURABLE MENTAL HEALTH POWER OF ATTORNEY IF YES, PLEASE BRING SUPPLY A COPY OF SUPPORTING DOCUMENTS TO INITIAL VISIT. YES NO CAN WE CONTACT YOU TO SET UP THE NEW PATIENT APPOINTMENT IF NO, WHO SHOULD WE CONTACT PHONE NUMBER REFERRAL INFORMATION WHO REFERRED YOU TO THE MEMORY CLINIC YES NO HAS THE PATIENT HAD A CONSULTATION AND WORK-UP FOR CURRENT SYMPTOMS IF YES, PLEASE PROVIDE: PHYSICIAN NAME DATE SEEN PHONE NUMBER YES NO DOES THE PATIENT HAVE A PRIMARY CARE PHYSICIAN IF YES, PLEASE PROVIDE: PHYSICIAN NAME PHONE NUMBER Page 1 of 6
CURRENT PROBLEM WHAT IS THE MAIN REASON FOR THE PATIENT’S VISIT TO THE CLINIC YES NO IS THE PATIENT MORE FORGETFUL YES NO DOES THE PATIENT REPEAT HIMSELF/HERSELF YES NO DOES THE PATIENT NEED REMINDERS YES NO DOES THE PATIENT FORGET APPOINTMENTS OR EVENTS YES NO DOES THE PATIENT HAVE TROUBLE WITH CALCUALTIONS/MANAGING FINANCES (i.e. balancing a checkbook) YES NO DOES THE PATIENT NEED HELP WITH PERSONAL CARE (i.e. eating, dressing, bathing or using the bathroom) YES NO DOES THE PATIENT HAVE TROUBLE FINDING WORDS OR FINISHING SENTENCES YES NO HAS THE PATIENT LOST INTEREST IN HIS/HER USUAL ACTIVITIES YES NO IS THE PATIENT SAD OR TEARFUL YES NO IS THE PATIENT IRRITABLE OR AGITATED WHEN WAS THE PROBLEM FIRST OBSERVED WHICH BEST DESCRIBES THE ONSET OF THE PROBLEM SUDDEN ONSET GRADUAL ONSET HOW HAS THE PROBLEM PROGRESSED OVER TIME STEP-WIDE PROGRESSION GRADUAL PROGRESSION WHAT MAKES PROBLEMS WORSE WHAT MAKES PROBLEMS BETTER MEDICAL HISTORY PLEASE LIST ANY BIRTH INJURIES OR ILLNESSES: PLEASE LIST ANY CHILDHOOD AND ADOLESCENT INJURIES OR ILLNESSES: YES NO HAS THE PATIENT HAD A BRAIN SCAN IF YES, LOCATION: DATE: YES NO HAS THE PATIENT HAD A STROKE IF YES, DATE(S): PLEASE LIST PAST AND CURRENT MEDICAL, NEUROLOGICAL AND PSYCHIATRIC PROBLEMS PROBLEM DIAGNOSIS DATE ACTIVE YES NO YES NO YES NO YES NO YES NO YES NO SURGICAL/HOSPITALIZATION HISTORY REASON FOR HOSPITALIZATION HOSPITAL DATE Page 2 of 6
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Page 5 and 6: SOCIAL HISTORY YEARS OF EDUCATION P
Page 7 and 8: HEALTH INSURANCE PLEASE COMPLETE TH

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