Comprehensive Brain Health Center of NY
55 West 39th Street, 15th Floor, New York, NY 10018
Tel.   315-816-4777

Memory and Dementia Clinic Screening Questionnaire

Patient Information:

• Full Name: _________________________

• Date of Birth: ___ / ___ / ______

• Age: ____

• Gender: □ Male □ Female □ Other

• Date of Visit: ___ / ___ / ______

Primary Concerns:

• Describe your primary concerns about memory or cognitive abilities:

• When did these symptoms first appear? _________________________________________

• Have symptoms worsened over time? □ Yes □ No

• Describe the progression (rapid, gradual, intermittent): _______________________

Memory and Cognition:

• Do you frequently forget recent events or conversations? □ Yes □ No

• Do you have difficulty concentrating or maintaining focus? □ Yes □ No

• Have you had difficulty remembering names or familiar faces? □ Yes □ No

• Have you gotten lost in familiar places? □ Yes □ No

• Do you have difficulty performing familiar tasks (e.g., cooking, driving)? □ Yes □ No

Activities of Daily Living and Functional Tasks: Please indicate if you require assistance or reminders with the following tasks and briefly explain any difficulties:

• Personal Hygiene:

  • Bathing/Showering: □ Yes □ No, explain: ______________________________________

  • Grooming (brushing teeth, shaving, combing hair): □ Yes □ No, explain: ________

• Dressing:

  • Selecting clothes suitable for the weather or events: □ Yes □ No, explain: ________

  • Putting on clothes independently: □ Yes □ No, explain: ________________________

• Medication Management:

  • Taking medications correctly and on time: □ Yes □ No, explain: ________________

• Meal Preparation:

  • Planning meals independently: □ Yes □ No, explain: ____________________________

  • Cooking safely (using stove, oven): □ Yes □ No, explain: _______________________

• Household Tasks:

  • Using household appliances (microwave, washing machine, phone): □ Yes □ No, explain: ___________________________________________________________

  • Keeping the home clean and organized: □ Yes □ No, explain: ____________________

• Financial Management:

  • Paying bills on time: □ Yes □ No, explain: ____________________________________

  • Managing bank accounts, balancing checkbooks, or budgeting: □ Yes □ No, explain: ______________________________________________________________

• Transportation:

  • Driving safely: □ Yes □ No, explain: __________________________________________

  • Using public transportation independently: □ Yes □ No, explain: _______________

• Shopping:

  • Shopping independently for groceries or necessities: □ Yes □ No, explain: _____

• Scheduling and Appointments:

  • Maintaining calendars or schedules: □ Yes □ No, explain: ______________________

  • Keeping track of appointments independently: □ Yes □ No, explain: ______________

• Social and Recreational Activities:

  • Engaging in hobbies or recreational activities independently: □ Yes □ No, explain: ______________________________________________________________

  • Maintaining social relationships or participating in community activities: □ Yes □ No, explain: __________________________________________________

Medical History:

• List any past or current medical conditions (e.g., diabetes, hypertension, stroke, depression):

• History of head injury or concussion? □ Yes □ No

  • If yes, please provide details: _______________________________________________

• History of seizures or neurological disorders? □ Yes □ No

Medications:

• List current medications, dosages, and frequency (including over-the-counter and supplements):

Family History:

• Is there a family history of memory problems, dementia, Alzheimer’s, or neurological conditions? □ Yes □ No

  • If yes, specify who and what condition: _______________________________________

Lifestyle:

• Do you smoke or use tobacco products? □ Yes □ No

• Do you consume alcohol regularly? □ Yes □ No

  • If yes, amount per week: _________________________________________________

• Describe your typical sleep pattern: __________________________________________

• Do you exercise regularly? □ Yes □ No

Mental Health:

• Have you experienced significant stress, anxiety, or depression recently? □ Yes □ No

• Have you noticed changes in mood or personality? □ Yes □ No

Sensory and Physical Symptoms:

• Have you experienced changes in vision or hearing recently? □ Yes □ No

• Have you noticed any issues with balance, coordination, or walking? □ Yes □ No

Additional Information:

• Provide any other information you feel may be relevant to your memory and cognitive health:

Signature (Patient/Guardian): _______________________________ Date: __________