This questionnaire will assist the medical team in completing your evaluation.
Please:
Today M-D-Y
Survey was completed in the following language:
English Spanish Cantonese Mandarin Other
Individual filling out this questionnaire:
Patient
Care partner/Informant
Patient and Care partner/Informant
Medical staff
Medical staff administered survey to:
Patient only
Care partner/informant only
Patient and care partner/informant together
Patient and care partner/informant at separate times
If the patient is unable to complete this questionnaire, please indicate the reason below:
Informants or caregivers filling out the questionnaire should answer the questions based on their understanding of what the patient is experiencing.
Patient's primary language/s?
If the patient does not speak English, hover HERE for details on cognitive testing
Patient's highest level of education:
No schooling Elementary school (grades 1-5) Middle school (grades 6-8) High school/GED (grades 9-12) College/University Postgraduate (Master's degree) Doctorate (PhD, MD, JD) Trade school
What is the patient's race?
Is the patient Hispanic or Latino?
Yes
No
Was the patient able to identify a care partner/informant?
Yes
No
Informant's primary language/s?
Care partner/informant relationship to the patient:
Child (blood, marriage, or adoption) Sibling (blood, marriage, adoption Parent (blood, marriage, adoption) Spouse, Partner, or Companion (include ex-spouse, ex-partner, fiancée) Daughter-in-law or Son-in-law Other relative (blood, marriage, adoption) Other (friend, neighbor, equivalent) Paid caregiver, health care provider, or clinician.
What is the number of years the care partner/informant has known patient?
0-1 year
1-5 years
5-10 years
10-15 years
greater than 15 years
Is the care partner/informant currently living with the patient?
Yes
No
Would you like to use this form to obtain the patient's History of Present Illness (HPI)?
Yes
No
History of Present Illness
CHIEF COMPLAINT
Hover HERE for the chief complaints interpretation table Hover HERE for other chief complaint prompts
Please do not enter any protected health information (PHI)
DURATION AND EARLY SYMPTOMS
Hover HERE for the duration and early symptoms interpretation table Hover HERE for other duration and early symptoms prompts
Please do not enter any protected health information (PHI)
CLARIFICATION - For any symptoms that the patient brings up, make sure that general terms like “I forget things” are clarified, usually it’s necessary to get examples Hover HERE for the clarification interpretation table Hover HERE for other clarification prompts
Please do not enter any protected health information (PHI)
EVOLUTION
Hover HERE for the evolution - changes in symptoms interpretation table Hover HERE for other evolution - changes comments
Please do not enter any protected health information (PHI)
EVOLUTION
Hover HERE for the evolution - new symptoms interpretation table Hover HERE for other evolution - new symptoms prompts
Please do not enter any protected health information (PHI)
POTENTIAL NON-NEURODEGENERATIVE CAUSES
Hover HERE for the non-neurodegenerative interpretation table Hover HERE for other prompts on non-neurodegenerative causes
Please do not enter any protected health information (PHI)
Survey Progress: ______ %Complete
1 Have you had any changes in your ability to manage basic activities of daily living due to changes in memory or thinking?
Hover here for the Basic Activities of Daily Living (BADLs) interpretation table
Hover here for other Basic Activities of Daily Living (BADLs) prompts
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Have you had any changes in your ability to manage basic activities of daily living due to changes in memory or thinking?
Yes No Don't know
Please provide further details and examples below
Yes
No
2 Has there been a change in your ability to manage your household due to problems with memory or thinking?
Hover here for the Instrumental Activities of Daily Living (IADLs) interpretation table
Hover here for other Instrumental Activities of Daily Living (IADLs) prompts
Has there been a change in your ability to manage your household due to problems with memory or thinking?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
Survey Progress: ______ %Complete
3 Do you have any problems with your memory or thinking? Hover here for the memory interpretation table Hover here for other memory prompts
Do you have any problems with your memory or thinking?
Yes No Don't know
If "YES" to ANY of the memory prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
4 Do you have difficulty expressing words, difficulty understanding words, or conversations?
Hover here for the language interpretation table
Hover here for other language prompts
Do you have difficulty expressing words, difficulty understanding words, or conversations?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
5 Do you have difficulty planning, starting or finishing complicated tasks at home or at work?
Hover here for the executive functions interpretation table Hover here for other executive functions prompts
Do you have difficulty planning, starting or finishing complicated tasks at home or at work?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
6 Do you ever get lost while walking or driving?
Hover here for the visual-spatial (walking or diving) interpretation table Hover here for other visual-spatial (walking or diving) prompts
Do you ever get lost while walking or driving?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
7 Do you have difficulty seeing things properly or judging distances properly?
Hover here for the visual-spatial (proper distance judgement) interpretation table
Hover here for other visual-spatial (proper distance judgement) prompts
Do you have difficulty seeing things properly or judging distances properly?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
8 Do you have difficulty recognizing people?
Hover here for the visual-spatial (facial recognition) interpretation table
No additional prompts
Do you have difficulty recognizing people?
Yes No Don't know
Please provide further details and examples below
Yes
No
Survey Progress: ______ %Complete
9 Have you noticed a change in your mood?
Hover here for the depression interpretation table Hover here for other depression prompts
Have you noticed a change in your mood?
Yes No Don't know
If "YES" to ANY of the depression prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
10 Have you lost motivation or energy to do the things you used to enjoy?
Hover here for the apathy interpretation table Hover here for other apathy prompts
Have you lost motivation or energy to do the things you used to enjoy?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
11 Do you become angry more easily?
Hover here for the anger interpretation table Hover here for other irritability/anger prompts
Do you become angry more easily?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
12 Sometimes we have patients who seem to forget how to behave in public. Has this been an issue for you?
Hover here for the disinhibition interpretation table
Hover here for other disinhibition prompts
Sometimes we have patients who seem to forget how to behave in public. Has this been an issue for you?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
13 Do you have any problems with beliefs that are unusual or not realistic?
Hover here for the delusions interpretation table
Hover here for other delusions prompts
Do you have any problems with beliefs that are unusual or not realistic?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
14 Do you see or hear anything that might not be there (or others can't see or hear)?
Hover here for the hallucinations interpretation table
No additional prompts
Do you see or hear anything that might not be there (or others can't see or hear)?
Yes No Don't know
Please provide further details and examples below
Yes
No
15 Have you become fixated on certain ideas that you can't get out of your head or have developed any specific rituals?
Hover here for the obsessions interpretation table Hover here for other obsessions/compulsions prompts
Have you become fixated on certain ideas that you can't get out of your head or have developed any specific rituals?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
16 Do you have any changes in sleep?
Hover here for the sleep interpretation table
Hover here for other sleep prompts
Do you have any changes in sleep?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
Survey Progress: ______ %Complete
17 Have there been changes in your eating habits?
Hover here for the eating behaviors interpretation table
Hover here for other eating behavior prompts
Have there been changes in your eating habits?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
Survey Progress: ______ %Complete
18 Do you seem less concerned about others' needs, problems?
Hover here for the empathy interpretation table
Hover here for other Loss of empathy prompts
Do you seem less concerned about others' needs, problems?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
Survey Progress: ______ %Complete
19 Do you seem to be more open to scams or solicitations?
Hover here for the judgement interpretation table
Hover here for other judgement/gullibility prompts
Do you seem to be more open to scams or solicitations?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
Survey Progress: ______ %Complete
20 Do you have involuntary shaking in your hands, arms, legs or chin?
Hover here for the Parkinsonism/resting tremors interpretation table No additional prompts
Do you have involuntary shaking in your hands, arms, legs or chin?
Yes No Don't know
Please provide further details and examples below
20.1
Yes
No
21 Do your limbs feel rigid or stiff?
Hover here for the rigidity interpretation table Hover here for other rigidity prompts
Survey Progress: ______ %Complete
Do your limbs feel rigid or stiff?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
22 Do you have twitching of your muscles?
Hover here for the motor neuron disease interpretation table Hover here for other motor neuron disease prompts
Do you have twitching of your muscles?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
Survey Progress: ______ %Complete
23 Have your movements been slowing down?
Hover here for the bradykinesia interpretation table Hover here for other bradykinesia prompts
Have your movements been slowing down?
Yes No Don't know
If "YES" to ANY of the badykinesia prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
24 Have you had any changes in your ability to walk?
Hover here for the parkinsonian and gait abnormality interpretation table
Hover here for other parkinsonian and gait abnormality prompts
Have you had any changes in your ability to walk?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
25 Have you fallen in the last couple of years?
Hover here for the frequent falls interpretation table
Hover here for other frequent falls prompts
Have you fallen in the last couple of years?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
26 Do you feel weaker on one side of your body than the other?
Hover here for the unilateral weakness interpretation table Hover here for other unilateral weakness prompts
Do you feel weaker on one side of your body than the other?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
Survey Progress: ______ %Complete
27 Do you have involuntary movements of your limbs, such as jerking or twitching?
Hover here for the myoclonus interpretation table Hover here for other myoclonus prompts
Do you have involuntary movements of your limbs, such as jerking or twitching?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
28 Does one of your arms behave as if it doesn't belong to you?
Hover here for the alien limb interpretation table Hover here for other alien limb prompts
Does one of your arms behave as if it doesn't belong to you?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
29 Do you have slurring of your speech?
Hover here for the dysarthria interpretation table Hover here for other dysarthria prompts
Do you have slurring of your speech?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
30 Have you had trouble swallowing?
Hover here for the dysphagia interpretation table
Hover here for other dysphagia prompts
Have you had trouble swallowing?
Yes No Don't know
If "YES" to ANY of the basic activities of daily living prompts, change the answer to "YES"
Please provide further details and examples below
Yes
No
Survey Progress: ______ %Complete
Are there any members of your family with "mental health problems, dementia, Parkinson's or other neurological problems"? For example: Alzheimer's disease, Parkinson's, schizophrenia, bipolar, depression.
Yes No Don't know
31 Are there any members of your family with "mental health problems, dementia, Parkinson's or other neurological problems"? For example: Alzheimer's disease, Parkinson's, schizophrenia, bipolar, depression.
Hover here for the family history interpretation table
No additional prompts
Please provide further details and examples below
Yes
No
Survey Progress: ______ %Complete
Would you like to use this form to conduct the patient's physical and neurological evaluation?
Yes
No
PHYSICAL AND NEUROLOGICAL EVALUATION
GENERAL APPEARANCE
personal hygiene and dress signs of trauma?
Hover HERE for the General Appearance interpretation table
Normal
Abnormal
CRANIAL NERVES
Hover HERE for the Cranial Nerves interpretation table
Normal
Abnormal
MOTOR - BULK
Hover HERE for the Motor - Bulk interpretation table
Normal
Abnormal
MOTOR - TONE
Hover HERE for the Motor - Tone interpretation table
Normal
Abnormal
MOTOR - POWER
Hover HERE for the Motor - Power interpretation table
Normal
Abnormal
MOTOR - TREMOR
Hover HERE for the Motor - Tremor interpretation table
Normal
Abnormal
MOTOR - OTHER PARKINSONIAN MOTOR FEATURES
Hover HERE for the Motor - Other interpretation table
Normal
Abnormal
MOTOR - MYOCLONUS
Hover HERE for the Motor - Myoclonus interpretation table
Normal
Abnormal
REFLEXES
Hover HERE for the Reflexes interpretation table
REFLEXES
Normal
Abnormal
STANCE
Hover HERE for the Posture and Stance interpretation table
Normal
Abnormal
GAIT
Hover HERE for the GAIT interpretation table
Normal
Abnormal
COGNITION
Standardized Cognitive Test score - MoCA, MMSE, SLUMS, 3MS, RUDAS
See the interpretation table for patients with 6 or more years of education and/or English speaking Hover HERE for the interpretation table for patients with low education and/or non-English speaking Please do not enter any protected health information (PHI)
Normal
Abnormal
*See interpretation manual for guidelines regarding need for administration of standardized cognitive test, scores and potential need for referral to dementia specialist.
IMAGING
Hover HERE for the imaging interpretation table
Please do not enter any protected health information (PHI)
Normal
Abnormal
LAB WORK
CBC METABOLIC PANEL TSH B12 RPR
Hover HERE for the Basic Lab Work interpretation table
Please do not enter any protected health information (PHI)
Normal
Abnormal
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