1. Site ID:
2. Patient UPIN:
3. Date (MMDDYYYY):
5. GPEU ID:
Time (24 hr)
There is a wide range of opinion about the effectiveness of FDA approved anti-Alzheimer's
medications in clinical practice. If the patient fulfilled the FDA approved diagnostic criteria
for drug treatment of dementia (i.e. mild to moderate Alzheimer's disease), please answer 1 of the
following 2 questions, depending on your treatment action or recommendation.
1. If you decided to prescribe ____________ (a FDA approved anti-Alzheimer's medication or
recommend it to the patient's medical provider, please select one or more reasons for your decision:
If other, please specify
3. Facial expression:
4. Tremor at rest:
5. Action or postural tremor of hands:
6. Rigidity: (judge on passive movement of wrist, elbows and shoulders with patient relaxed in sitting position. Cogwheeling to be ignored.)
7. Body bradykinesia and hypokinesia: (Combining slowness, hesitancy, decreased armswing, small amplitude, and poverty in movement in general.)
Please answer the following questions based on changes that have occurred since he/she first began to experience memory problems.
Select "Yes" only if the symptom(s) has been present in the last month.
Select "No" only if the symptom(s) has not been present in the last month.
Otherwise, select "N/D." For each item marked "Yes":
a) Rate the SEVERITY of the symptom (how it affects the patient):
1 = Mild (noticeable, but not a significant change)
2 = Moderate (significant, but not a dramatic change)
3 = Severe (very marked or prominent, a dramatic change)
b) Rate the DISTRESS you experience due to that symptom (how it affects you):
0 = Not distressing at all
1 = Minimal (slightly distressing, not a problem to cope with)
2 = Mild (not very distressing, generally easy to cope with)
3 = Moderate (fairly distressing, not always easy to cope with)
4 = Severe (very distressing, difficult to cope with)
5 = Extreme or Very Severe (extremely distressing, unable to cope with)
Please answer each question honestly and carefully.
Ask for assistance if you are not sure how to answer any questions.
Does the patient believe that others are stealing from him/her or planning to harm him/her in some way?
Does the patient act as if he/she hears voices? Does he/she talk to people who are not there?
Is the patient stubborn and resistive to help from others?
12. Depression (Dysphoria)
Does the patient act as if he/she is sad or in low spirits? Does he/she cry?
Does the patient become upset when separated from you? Does he/she have any other signs of nervousness such as shortness of breath, signing, unable to relax, or feeling excessively tense?
Does the patient appear to feel too good or act excessively happy?
Does the patient seem less interested in his/her usual activities and in the activities and plans of others?
Does the patient seem to act impulsively, for example, talking to strangers as if he/she knows them, or saying things that may hurt people's feelings?
Is the patient impatient and cranky? Does he/she have difficulty coping with delays or waiting for planned activities?
18. Motor Disturbance
Does the patient engage in repetitive activities such as pacing around the house, handling buttons, wrapping string, or doing other things repeatedly?
19. Nighttime Behaviors
Does the patient awaken you during the night, rise too early in the morning, or take excessive naps during the day?
Has the patient lost or gained weight, or had a change in the type of food he/she likes?
(Not included in ARCC Treatment Evaluation Supplement)
21. Since our last evaluation (or within 6 months of the initial visit), has Ms./Mr. ______
(Patient's name) been to the emergency room or urgent care, been hospitalized, or been placed in a
nursing home or respite facility?
If yes, briefly describe:
If yes, please mark all that apply:
Illness, accident, or surgery requiring hospital admission or urgent care
Caregiver currently too frail or impaired to provide care
Placed in temporary respite
Placed in nursing home
22. Please circle all of the following that have been a problem in the last month:
Verbally abusive and hostile
Loss of mobility sufficient to require daily assistance
IHA Use Only: Indate (MMDDYYYY):