Geriatric Memory Loss Specialist Intake

Patient Information

Full Name Date of Birth Age Gender Female Male Other Phone Address

Referral Information

Referring Physician Primary Care Physician Emergency Contact Name Emergency Contact Phone Relationship

Presenting Concerns

Memory Issues Noticed Since Describe Concerns Any Sudden Changes? Yes No Other Observed Symptoms

Medical and Social History

Past Medical Conditions Current Medications History of Falls Yes No History of Substance Use Living Situation Family History of Dementia

Mental Status and Function

Difficulty with Activities of Daily Living Other Cognitive or Mood Changes Additional Comments