Informant Cognitive Decline Questionnaire Form
An informant form to describe observed memory, thinking, and daily functioning changes in a person. Please use the same title exactly across the form and keep the design clean, premium, and minimal.
Informant and Person Being Observed
Informant's relationship to the person being observed
*
Family member
Friend
Caregiver
Other
Informant's name
*
Person being observed's name or initials
*
Best contact method for follow-up
*
Phone
Email
Other
Observed Cognitive Changes
Have you noticed any cognitive changes?
*
Yes
No
Unsure
Which changes have you observed?
Memory loss
Confusion
Trouble finding words
Repeating questions
Getting lost
Difficulty managing finances
Difficulty managing medications
Changes in judgment
Other
How concerning are these changes overall?
*
Not concerning
1
2
3
4
5
6
7
8
9
Extremely concerning
10
1 is Not concerning, 10 is Extremely concerning
Impact and Timing
When were the changes first noticed?
-
Month
-
Day
Year
Date
How often are the changes observed?
*
Daily
Weekly
Occasionally
Unsure
How much do the changes affect daily activities?
*
Not at all
1
2
3
Severely
4
1 is Not at all, 4 is Severely
Submit
Should be Empty: