The Northeast Pennsylvania Memory & Alzheimer s Center

Transcription

1 The Northeast Pennsylvania Memory & Alzheimer s Center Patient Name Date Completed 1. Name of Person Filling Out (if other than patient) a. Relation to patient 2. Who referred you or how did you find out about the Center a. If referral, reason for referral 3. Do you or someone else have concerns about you memory? Yes No If yes who 4. What is your major concern that brings you to the center? 5. List up to 3 other issues related to your major concern a. b. c. 6. Medications Please list all of your medications, both prescription and over the counter. Please include the dosage and how often you take the medication. Please include vitamins and any alternative treatments you are receiving. If you live at home please bring ALL these medications with you to your appointment. If you live in a Nursing Home please bring a medication list with doses from the facility.

2 Medications Dosage Frequency Office Use Only Prescription Meds brought in at time of visit: Yes No OTC Meds brought in at time of visit: Yes No Reviewed By

3 7. Allergies: Please list all medications to which you are allergic and what happens when you take them (example rash or swelling). Include medications you cannot take for reasons other than allergy and state what happens when you take them (for example nausea, vomiting). 8. Past Medical History: Please circle illnesses you have now or have had in the past. Alcoholism Alzheimer's disease or other dementia Anemia Arthritis Bowel Problem Cancer Chickenpox Depression Diabetes Epilepsy (seizure) Ear Problem Eye problem Gallbladder disease Gout Heart Problem Hemorrhoids High Blood Pressure HIV (AIDS virus) Fractures Falls Head Trauma Loss of consciousness Lyme disease Internal bleeding Kidney problems liver problems Headaches Nervous breakdown Parkinson's disease Paget's disease Phlebitis Pneumonia Rheumatic Fever Stomach ulcer Stroke Thyroid Problems Venereal disease

4 9. If you have had an MRI, CAT Scan or PET Scan of the brain please list below and please bring the reports with you to the center. Test Date Where Done 10. Surgeries: Please list all surgeries. Surgery Date Hospital 11. Hospitalizations: Please list all hospitalizations in include to reason and the approximate date. Please include hospitalizations for psychiatric reasons. Reason Date Hospital 12. Please circle yes or no. a. Have never been tested for Lyme disease? Yes/No b. Have you ever had a blood transfusion? Yes/No c. Do you see an eye doctor? Yes/No

5 13. Health Habits i. If yes, when, was your last appointment? a. Do you smoke cigarettes or use other tobacco products? Yes/No i. If no, have, you ever used cigarettes were other tobacco products? Yes/No ii. If you have quit using tobacco products, when did quit? b. Do you drink alcohol? Yes/No If yes, how often do you drink alcohol? a. Rarely (once or twice a year.) b. Once to twice a months c. Once to twice a week d. 3 or more times a week c. Do you get any regular exercise? Yes/No i. If yes, described her exercise routine. 14. Family Medical History Complete medical problems as best you can. Write A if the relative is alive. Write a D if the relative is dead, and cause of death is known. Spouse Children Brothers

6 Sisters_ Mother Father_ 15. Social History/Social Support a. Year you born? b. Please give me a brief description of your present home c. In the last 5 years had he been a victim of any crime? Yes/No d. Have you ever been a victim of abuse? e. Do you know your neighbors well enough to ask for immediate assistance if needed? Yes/No f. What is your marital status? Married Widowed Divorced Separated Never married g. Do you live alone? Yes/No If no, with whom do you inserted after live? h. Do you have a pet? Yes/No.

7 i. What was the highest level of education, you attained? Years of elementary school Years of high school Years of college Years of graduate school Right or Left Handed (circle) j. What was your occupation? (If retired, indicate your prior occupation) k. Were you ever in the military? Yes/No l. If you felt lonely and wanted to companionship, what would you do? m. Yes/No Over the past year, has there been any significant changes or losses in your life? If Yes, briefly describe n. Yes/no Are you able to balance her checkbook and manage her money? o. Yes/no Do have enough money to meet you normal monthly expenses? p. Yes/No Do you have any financial concerns: q. Yes/no Do you go to religious activities? r. Yes/no Do you attend in the senior activities? s. Is there any recreation or hobby in which you regularly participate? Is Yes, please list If no, please list, former interests t. Yes/no Do you do your own shopping and cooking? If no, who does it for you? u. Yes/no Do you drive an automobile?

8 v. Yes/no Do you using an emergency response system such as Lifeline? w. Yes/no Do you we Medic Alert identification bracelet or necklace? x. Do you receive any of the following services: mental health services or therapy regularly provided meals such as Meals on Wheels legal help help with household chores assistance with personal care, such as bathing and dressing assistance with transportation needs Church assistance adult daycare