Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Unknown
In general, would you say your loved one's health is:
Excellent
Very Good
Good
Fair
Poor
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Health Information & History
What medical conditions, if any, apply to your loved one? Click on a condition to move it to your column.
*
Please describe the 'Other' condition:
List any past surgeries:
Has your loved one had any of the following in the past 6 months:
Fall or accidental injury
Sudden change in behavior or sleep
Behavior changes
Unexplained weight loss
ER visit
Hospital admission
Please share how many ER visits / hospital admissions have occurred in the past 6 months?
Feel free to share any additional details if you selected one or more events.
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Medications
Please share what medications, if any, are currently being taken. Would you like to enter those below or share a picture?
Enter manually
Share a picture
Use the button below to upload a picture/file of medications. Be sure the list includes any drops, sprays, over-the-counter medications, and/or supplements.
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Use the table below to enter the medications. Be sure to include any drops, sprays, over-the-counter medications, and/or supplements.
List any allergies your loved one may have, especially any medication allergies:
*
Please share estimated dates of any vaccinations that were recently received:
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Social History
How many days of moderate to strenuous exercise, like a brisk walk, did the person do in the last 7 days?
days
Does or has your loved one ever smoked tobacco?
*
Please Select
Never smoker
Former smoker
Current every day smoker
Current some days smoker
How much tobacco is usually smoked?
1 pack or less per week
2 packs per week
1/4 pack per day
1/2 pack per day
1 pack per day
2 packs per day
3 or more packs per day
Does or has your loved one ever used other forms of tobacco or nicotine?
*
Yes
No
What's the most number of drinks your loved one might have in one week?
Never
Less than 7 drinks per week
7-14 drinks per week
14+ drinks per week
What's the most number of drinks your loved one might have in one week?
Never
less than 3 drinks per week
3-7 drinks per week
7+ drinks per week
What is the level of alcohol consumption?
None / Occasional / Moderate / Heavy
Does your loved one use or have a history of using non-prescribed medications including recreational drugs like marijuana, illicit medications, or IV drugs?
Please Select
Never user
Former user
Current every day user
Current some days user
Not tolerated
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Healthcare Providers
Who is your loved one's primary care physician?
*
Please list any other healthcare providers and/or any key contacts related to that person's health, specifically any clinicians caring for dementia being seen such as a neurologist or psychiatrist. If you select 'Other', please describe their role in 'Provider Name'.
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Submission
Please share about your loved one's current living situation.
Tell us about any goals or challenges that you feel we could help with. Also feel free to share any additional details or questions you may have regarding your loved one's health.
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