Memory Service Questionnaire

Please complete this form with as much detail as possible.

Name(Required)

First Last

Date of Birth(Required)

What is your reason for the assessment with our memory service?(Required)

Has the patient already been seen by their GP?(Required)

Yes

If the patient has already been seen by their GP, when was the consultation regarding this concern?

If the patient has already been seen by their GP, what was the outcome of the consultation?

Have they been seen by their local NHS dementia service?(Required)

Yes

If the patient has been by the local NHS dementia service, what was the outcome of their assessment?

Have you been advised of the wait time to see an NHS specialist (NHS Memory Team)?(Required)

Please list your area(s) of concern:(Required)

What date was a memory problem first noticed?(Required)

Is the patient aware of the problem(s)?(Required)

Yes

Please record any information you think is relevant to the assessment or may assist our memory team:(Required)

Declaration(Required)

I declare that I have checked the details I have given on the enclosed questionnaire and that, to the best of my knowledge and belief, they are correct.

Name of person completing form:(Required)

First Last

Today's date:(Required)

Relationship to patient:(Required)