Memory Clinic — New Patient Form

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Patient

NameUMRN

Reason for referral

History

Cognitive symptomsOnsetTime course & progress

Cognitive domains

MemoryLanguageVisuo-spatialExecutiveAttentionGnosis

Impact & Behaviour

Impact of cognitive symptomsBehavioural symptomsSleep pattern

Function

DrivingCommunity activitiesPersonal ADLsInstrumental ADLsSafety issues

Medical History

Past Medical HistoryAlcoholSmokingMedicationsAllergies

Social History

EducationOccupationLiving ArrangementSupportServices and Approvals

Others

Family HistoryMobility/FallsContinenceNutritionWhat Matters Most?EPG / EPA / AHD

Examination

GeneralCardiovascularNeurologicalGait & balance

Cognitive testNotes

If functional impairment on history: MMSE & Clock Drawing Test. If no functional impairment on history or highly educated: MoCA. If NESB/non-Western education: RUDAS.

Investigations

BloodsECGImaging

Impressions and Issues

DiagnosisSupports / safety issues / other concernsCriteria met for medication

Plans

InvestigationsReferralsInformation ProvidedMedication ChangesAdvanced planning discussion

Generated Note

(Nothing generated yet)