Cognitive Symptom Questionnaire

Patient's Name *

Your Name *

Please select your relationship to the patient:

Please select how often you spend time with the patient?

How long have you known the patient?

When did you first notice the symptoms?

Memory Difficulty

Please indicate whether you have noticed the RECENT ONSET or worsening of any of these signs of
MEMORY DIFFICULTY

Failing to pass on messagesNot ReallySometimesDefinitely

Forgetting about recent eventsNot ReallySometimesDefinitely

Forgetting something they were told a few minutes agoNot ReallySometimesDefinitely

Forgetting appointmentsNot ReallySometimesDefinitely

Inability to concentrateNot ReallySometimesDefinitely

Saying the same thing over and over againNot ReallySometimesDefinitely

Difficulty thinking of words they want to useNot ReallySometimesDefinitely

Easily getting lostNot ReallySometimesDefinitely

Failing to recognize a place they have visited beforeNot ReallySometimesDefinitely

Forgetting the names of people and placesNot ReallySometimesDefinitely

Forgetting characters’ names while watching a TV programmeNot ReallySometimesDefinitely

Forgetting what day it isNot ReallySometimesDefinitely

Getting the present mixed up with the pastNot ReallySometimesDefinitely

Deciding to do something and forgetting after a few minutesNot ReallySometimesDefinitely

Forgetting to do something even though it is in front of them (e.g. taking pills)Not ReallySometimesDefinitely

Forgetting to buy things that they went out shopping forNot ReallySometimesDefinitely

Mislaying things they have just put downNot ReallySometimesDefinitely

Forgetting what they watched on TV yesterdayNot ReallySometimesDefinitely

Easily getting lostNot ReallySometimesDefinitely

Failing to pass on messagesNot ReallySometimesDefinitely

Repitions of a favourite word

Repetitive speech can take a number of forms: some people use a particular word over and over again when they are talking.

How often do you hear REPETITIONS OF A ‘FAVOURITE’ WORD?Many times a dayA few times a dayHardly at all/Never

Are there any specific circumstances (e.g.: in company, on the phone, when stressed, particular times of the day)? If so, please specify:

Can you recall any examples of frequently repeated words? If so, please write up to three of them below:

Repitions of same phrase

Others repeat familiar catchphrases (e.g. ‘at the end of the day’; ‘it takes all sorts”), or statements (e.g. ‘it’s very cold today’).

How often do you hear REPETITIONS OF A ‘FAVOURITE’ WORD?Many times a dayA few times a dayHardly at all/Never

Are there any specific circumstances (e.g.: in company, on the phone, when stressed, particular times of the day)? If so, please specify:

Can you recall any examples of frequently repeated phrases or sentences? If so, please write up to three of them below:

Repetitions of same question

Some people may also ask questions repeatedly (e.g. ‘what day is it today?’; ‘what time are we leaving?’).

How often do you hear REPETITIONS OF THE SAME QUESTION?Many times a dayA few times a dayHardly at all/Never

Are there any specific circumstances (e.g.: in company, on the phone, when stressed, particular times of the day)? If so, please specify:

Can you recall any examples of frequently repeated questions? If so, please write up to three of them below:

Awareness/Insight

Do you think that he/she has any AWARENESS of or INSIGHT into his/her problems?

Memory problemsAwareUnawareDoes not have these problems

Language difficultiesAwareUnawareDoes not have these problems

Changes in behaviour or personalityAwareUnawareDoes not have these problems