NeuroBali · Questionnaire / scoring
Intake form
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Memory concern baseline
Initial questions about memory change, daily function, mood, sleep, medication, and family concerns.
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This form helps patients and families organise memory concerns in a structured way. Print, complete together, and bring to consultation.
Basic information
- Full name
- Date of birth
- Date completed
- Completed by (patient / family)
Memory changes
01 When did the family or patient first notice the change?
02 Did the change start suddenly, gradually, or fluctuate?
03 Concrete examples that occur most often (missed appointments, repeated questions).
Daily function
01 Can the patient still manage finances, bills, and banking independently?
02 Any difficulty taking medications at the correct time or dose?
03 Has the patient gotten lost in places they usually know?
04 Has work, hobbies, or social activity declined?
Mood & sleep
01 Any changes in mood, anxiety, or social withdrawal?
02 Sleep pattern: duration, quality, snoring, or waking confused?
03 Have there been brief episodes of acute confusion?
Medications & medical factors
01 Current medication list, including sleep, pain, or allergy medicines.
02 History of hypertension, diabetes, cholesterol, stroke, or heart disease.
03 History of head injury, major anaesthesia, or prior brain infection.
Family concerns
01 What is the family's biggest concern right now?
02 Any family history of dementia or Parkinson's disease?
03 What is the goal of this evaluation (baseline, diagnosis, treatment plan)?