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Memory and Behavior Clinic - Self Report Form
Instructions: This form will take 15-20 minutes to complete. Please take the necessary time to gather
information and carefully answer all questions. If you do not know the answer to a question, please write "DK."
PATIENT INFORMATION
Name: DOB: Age:
Address: Phone:
Is English your primary language? Yes No
If no, please list your primary language:
Do you have a designated power of attorney for health care, or a court-appointed legal guardian who is
regularly involved in making your health care decisions?
Yes No
If yes, please specify: Power of attorney Court-appointed guardian
If yes, please state name and phone number for the guardian or power of attorney, and have him/her
sign the signature line below.
Name:
Phone:
Signature:
Please list below any individual(s) who will be accompanying you to the clinic:
INSURANCE INFORMATION
Insurance Company: Policy Number:
Name of Policy Holder: Group Number:
Date of Birth: Phone # for Claims:
If applicable, provide information for additional policy below:
Insurance Company: Policy Number:
Name of Policy Holder: Group Number:
Date of Birth: Phone # for Claims:
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PURPOSE OF EVALUATION
Why are you seeking evaluation at this time?
Were you referred to this clinic by a health care professional, or are you self-
referred?
What were the first problems you noticed?
When did you first notice the problems?
How did the problems appear? Started suddenly Appeared gradually over time
How would you describe the problem(s)?
Steadily worsening Fairly stable over time Steadily improving
Tendency to come and go (good days and bad days)
What memory or behavior problems (if any) have family or friends told you they have observed?
Are there any circumstances or activities that result in improvements in your symptoms?
If yes, please describe:
What are the most important things you would like to see accomplished with this evaluation?
MEDICAL INFORMATION
Primary Care Physician:
Address:
Phone:
Have you seen your primary care physician about the current issue? Yes No
If yes, approximately when were you seen?
Have you been seen by any other doctor or specialist about the current issue? (e.g.,
neurologist, psychiatrist, psychologist) Yes No
If yes, please list
doctors and contact
info:
Have you ever seen a neurologist for any reason? Yes No
If yes, when and why were you seen?
Have any tests concerning this issue been performed in the past two years? (e.g., MRI,
CT scan, lab work, blood work, neuropsychological testing) Yes No
If yes, please list:
Test Performed Ordering Physician
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MEDICAL HISTORY
Please mark any of the following conditions that you have had, and indicate the year when each started. If not
certain, please write down an approximate year or age when the problem began.
Neurological Illness Year Cardiac Illness Year
Head Injury Heart Attack
Stroke High Blood Pressure
Seizures / Convulsions High Cholesterol
Multiple Sclerosis Chest Pain
Parkinson's Disease Bypass Surgery
Fainting Spells Stent Placement
Dizziness Congestive Heart Failure
Shortness of breath Atrial Fibrillation
Headaches Palpitations
Migraine Headaches
Other
neurological
illness (please
list):
General Medical Illness Year Year
Asthma Gastrointestinal Problems
Cancer Diabetes
Thyroid Disease Significant Weight Loss
COPD / Emphysema Significant Weight Gain
Allergies / Hayfever Difficulty Swallowing
Frequent Hospitalizations Exposure to Toxins
Glaucoma Ringing in the Ears
Cold or Heat Intolerance Unexplained Fatigue
Other:
Do you suffer from chronic or severe pain?
If yes, please describe the location and severity (scale of 1-10) of the pain:
Please list any major childhood illnesses:
Please list any prior surgical procedures:
Do you have a family history of dementia or Alzheimer's disease? Yes No
If yes, please describe:
Do you have a family history of memory loss? Yes No
If yes, please describe:
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Do you have a family history of neurological illness (e.g., epilepsy, multiple sclerosis, Parkinson's disease,
Lou Gehrig's disease)?
Yes No
If yes, please describe:
Is there a strong family history of any particular medical illness (e.g., heart disease, diabetes, cancer)?
Yes No
If yes, please describe:
Do you smoke or chew tobacco? Yes No If yes, how much per day?
Do you drink alcohol? Yes No If yes, how much per week?
Do you drink caffeinated beverages? Yes No If yes, how much per day?
Do you have any hearing impairment? Yes No
If yes, do you wear a hearing aid? Yes No
Do you have impaired vision? Yes No
If yes, please describe:
Do you wear glasses? Yes No For reading only? Yes No
Do you wear contacts? Yes No
Have you had vision correction surgery? Yes No
What is your handedness? Right Left Ambidextrous
MEDICATIONS
Please list all medications you are currently taking. This includes prescriptions, over-the-counter medications,
inhalers, eye drops, topicals, vitamins, herbal supplements, etc.
Check here if you are currently not taking any medications
See attached list
How taken?
Date Last Reason for Prescribing
Medication Name Dose How often? (oral, topical,
Taken Medication Physician
etc.)
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BEHAVIORAL SYMPTOM CHECKLIST
Please indicate behaviors and/or symptoms that you have noticed in yourself.
Check all that apply.
Orientation (Check all that apply)
Periods of severe confusion
Confusion about what day of the week it is
Confusion about what year it is
Difficulty recognizing where you are
Difficulty recognizing people you should know
Attention / Concentration (Check all that apply)
Highly distractible
Difficulty thinking as quickly as needed
Episodes of your mind "going blank"
Taking a long time to respond to questions
Feeling overwhelmed if several things are happening at once
Other attention/concentration problems (please describe):
Judgment, Organization, and Problem Solving (Check all that apply)
Difficulty planning ahead
Difficulty changing plans when necessary
Difficulty completing an activity in a reasonable amount of time
(e.g., taking 45 minutes to get dressed)
Not starting or participating in conversations (e.g., sitting quietly in a lively conversation)
Behavior that others tell you is silly, childlike, or inappropriate
Lack of attention to important matters (e.g., not paying bills)
Telling stories that others have told you cannot possibly be true
Others are questioning your financial decisions
Other judgment/organization problems (please describe):
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Speech and Language (Check all that apply)
Difficulty recalling the names of common objects
Effortful speech (i.e., feeling like you have to "force" words to come out)
Using the wrong names for things (e.g., calling the TV a radio)
Difficulty finding the right word (e.g., word is on the tip of your tongue, but you can't
come up with it)
Slurred speech, stuttering speech, or speech that does not flow smoothly
Using made-up words (e.g., calling the remote control a "point-at-er")
Difficulty understanding what others are saying
Significant change in speech volume (e.g., speech has become much softer or louder)
Difficulty reading
Change in handwriting (e.g., becoming smaller; becoming more difficult to read; taking
longer to write)
Other language problems (please describe):
Visual Functioning (Check all that apply)
Double vision
Blurry vision
Brief periods of blindness
Needing to squint or move closer to objects in order to see them
Sensitivity to bright lights
Difficulty finding objects that are in plain sight
Walking into objects (e.g., the edge of a doorway, the corner of a table)
If yes, are objects on the: right left both sides don't know
Difficulty recognizing familiar people
Difficulty recognizing familiar places (e.g., not knowing where you are, even in your
own home)
Getting lost easily
Other visual problems (please describe):
Memory (Check all that apply)
Rapid forgetting (e.g., repeating the same question within five or ten minutes)
Frequently losing important things (e.g., keys, credit cards)
Forgetting the names of familiar people
Forgetting events from the past
Difficulty remembering recent events (e.g., forgetting a conversation from a few days before)
Difficulty learning new things (e.g., how to operate a new microwave)
Other memory problems (please describe):
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Motor & Sensory Functioning (Check all that apply)
Problems with balance
Slowed and/or unsteady gait
Using an assistive device (e.g., cane, walker, wheelchair)
Difficulty getting out of a chair
Tendency to fall
If yes, do you fall: backward forward to the side don't know
Weakness on one side of your body
If yes, please indicate: right left
Shaking or tremors
Loss of feeling or numbness
Tingling or other unusual sensations
Loss of sense of taste or smell
Tics or other unusual movements
Difficulty with fine motor control (e.g., difficulty accurately pushing the buttons on the
telephone)
Difficulty with well-learned motor tasks (e.g., operating the telephone or the remote control)
Needing assistance with daily activities because of mobility difficulty (e.g., dressing,
bathing, eating)
No difficulty performing daily activities, but you are significantly slower
Other motor problems (please describe):
Home / Community Functioning (Check all that apply)
Others have expressed concern about your personal hygiene
Others have expressed concern about your eating habits
Others have expressed concern that you are not keeping up your home (e.g., dishes
not washed, garbage not taken out, spoiled food in refrigerator)
Difficulty cooking (e.g., burning food, leaving stove on, forgetting simple recipes)
Trouble with bill paying (e.g., missing payments, late charges)
Incontinence
If yes, please specify: bladder bowel both
Difficulty making correct change in a store or restaurant
Other functioning problems (please describe):
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Emotional Functioning, Personality, & Mental Health (Check all that apply)
Feeling sad much of the time
Episodes of euphoria
Thinking or talking a lot about death
Suicidal thoughts (e.g., "It would be better if I wasn't here")
Feeling anxious much of the time
Difficulty falling asleep
Strong focus on certain topics or fears (e.g., finances)
Feeling excessive fear (e.g., spouse having affair, children stealing money, house being
broken in to)
Laughing when no one else is
Much more emotional than usual
Not enjoying activities that were once pleasurable
Increasing inactivity and lack of participation in activities
Change in your personality
Sudden or rapid mood swings
Angry or irritable more than usual
Agitated (e.g., pacing the floor)
Change in sexual behavior
Aggressive behavior (e.g., hitting, yelling, making threats)
Having hallucinations (i.e., responding to sensory stimuli that are not real)
If yes, please
specify: visual auditory tactile (e.g., feeling things on skin)
Other emotional problems (please describe):
Driving (Check all that apply)
Are you currently driving? Yes No
If no, when did you stop? Why?
Have you noticed any driving difficulties?
Yes No
Have others expressed concern about your driving abilities?
Yes No
If you answered yes to either of the two previous questions, please specify:
Drifting over the line when driving
Having difficulty finding familiar destinations
Driving too close to other vehicles
Driving too slowly (e.g., 20 mph in a 45 mph zone)
Disagreeing with the advice of family members or health care providers to stop driving
Getting lost and having to call for directions, or getting lost and simply showing up
several hours later
Other driving problems (please describe):
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Other Symptoms (Check all that apply)
Disliking changes in routine
Confusion about what is a dream and what is real
More confusion late in the day
Awakening at night (i.e., disruption of day/night pattern)
Excessive sleeping (more often asleep than awake)
Frequent nightmares
Please use the space below to describe any additional symptoms that you believe need to be considered in this
evaluation:
PERSONAL HISTORY INFORMATION
Some historical information will help us better understand the patient.
ACADEMIC HISTORY
How many years of education do you have (check one):
Did not complete high school
If you did not complete high school, please specify how many years of
school were completed:
If you did not complete high school, did you earn a GED? Yes No
Completed high school
Completed some college, did not earn a degree
If you did not earn a degree, please specify how many years of college
were completed:
Completed vocational or trade training / apprenticeship
Completed 2-year degree Field of study?
Completed 4-year degree Field of study?
Completed Masters degree Field of study?
Completed Doctoral degree Field of study?
What type of student were you? below average average above average
Were you considered to have a learning disability or to be a "slow learner?" Yes No
Did you have behavioral difficulties in school? Yes No
VOCATIONAL HISTORY
What was/is your primary career? (please list "homemaker" if appropriate):
If more than one, please list:
Have you retired? Yes No If yes, when:
Please list brief work history:
Position Held Years Held (approximate)
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SOCIAL HISTORY
Where were you born?
Who were you raised by?
How many siblings do you have?
Were you exposed to severe early-life stress (e.g., loss of parent, divorce, physical or sexual abuse,
exposure to war)?
Yes No If yes, please explain:
Have you had any recent severe stress (e.g., death in the family, severe financial stress)?
Yes No If yes, please explain:
Marital Status: Married Single Divorced Widowed Other
If currently married, how many years have you been married?
Do you have any children? Yes No
If yes, please list children and the city and state where they live:
Who is/are your primary source(s) or emotional support?
Do you maintain regular social contacts? Yes No
If yes, with whom:
Do you participate in recreational activities? Yes No
yes,
If y , describe:
What is your current living arrangement? (check one):
Live at home independently Live at home with assistance Live with family
Senior community Other (please specify):
Who currently lives in your residence?
Are you home alone during the day?
Does anyone assist you with paying your bills? Yes No
If yes, describe:
MENTAL HEALTH HISTORY
Have you ever received treatment by a psychiatrist, psychologist, or counselor? Yes No
If yes, when were you treated?
What were you treated for (diagnosis)?
Have you ever been psychiatrically hospitalized? Yes No
Do you have a history of suicidal thoughts or behavior? Yes No
Have you ever made a suicide attempt? Yes No
Do you have a history of homicidal thoughts or behavior? Yes No
Do you have a history of alcohol abuse? Yes No
Have you ever experienced alcoholic blackouts or "DTs"? Yes No
Have you ever used recreational drugs? Yes No
If yes, what drugs did you use?
Have you ever abused prescription drugs? Yes No
If yes, what drugs did you abuse?
Have you ever been treated for alcohol or substance abuse? Yes No
Have you had alcohol or substance-related legal problems? Yes No
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Please complete this form and return it to us in one of the following ways:
a. Fax to Delnor Psychological Services at 630-208-3007
b. Drop off at the Delnor Hospital Atrium
c. Mail to the following address: Attn: Memory and Behavior Clinic
Suite 30
Delnor Hospital
300 Randall Road
Geneva, IL 60134
If you have any questions about completing this form, please call Delnor Psychological Services at
(630)524-5845.
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