MEMORY DISORDERS CLINIC EVALUATION 

 (format by J. Wesson Ashford, M.D., Ph.D., 2/21/2002)

ID:   yr old   RACE   GENDER 

Living situation:

Referral source:

Reason for referral:

Who accompanied:

CC: 

HPI:

   Prior cognitive difficulties:

   Onset date:

   Initial symptoms:

   Course:

   Current Severity:

PMH:

   MI:   HTN:   DM:   CA:   TB:   HI:

MEDS:

SMOKING: Age started:

          Pack years:

ETOH:    

ROS:

   Sleep:

   Activity:

   Mood:

FMHx:          age at death     cause of death    dementia/memory probs

   Mother:

   Father:

   Brothers:

   Sisters:

   other relatives:

    (GPs, A&Us)

   Other family:

SHX:

   Born:

   Education:

   Military service:

   Occupation:

   Marital status:

   Children:

   Housing:

IADLS:

   Medication management:

   Money management:

   Transportation:

   Meal preparation:

   Housekeeping:

   Shopping:

   Laundering:

   Home maintenance:

   Telephone use:

   Reading:

   Leisure:

BADLs:

   Ability to feed self:

           Nutrition:    

           Appetite

           Difficulty swallowing

   Continence-    bowel and bladder

Who would assist you if you needed assistance?

Community resources:

Vision:

Hearing:

LABS:

Chemistry panel:

CBC:

ESR:

PSA:         

Lipid Prof:

Thyroid FTs: Thyroid Profile

RPR:        (?HIV)         

Vit B12:      

Folate:    

Gly Hgb:

Homocystine:

Methly-malonic acid:

CXR:

EKG:

RUA:

BRAIN IMAGING:

        CT:

        MRI: 

        SPECT:

MSE:    Appearance:

        Behavior:

        Interaction:

        Mood:

   Depression screen:

   1. During the past month, have you been bothered by feeling down,

depressed or hopeless?

   2. During the past month, have you often been bothered by little

interest or pleasure in doing things?

        Psychotic ideation:

        Insight / judgement:

Cognitive Status Exam

        Personal orientation:   /10

        Temporal orientation:   /5

        Place orientation:        /5

        Remote memory (Pres):   /5

        Recent memory (5 it):    /5

        Attention

                WORLD bac:    /5

                serial 7s:  /5

        Figure copying

                Pentagons:   /1

                Cube:         /1

        Animal naming:

                30 secs:  

                1 min:

        Clock drawing:

IMPRESSION:

RECOMMENDATIONS:

RTC: