Get Baylor Memory Center

Filling out the Baylor Memory Center questionnaire is an essential step in ensuring that you receive the best possible care and evaluation. This guide provides clear instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the Baylor Memory Center questionnaire.

1. Click ‘Get Form’ button to obtain the questionnaire and open it for editing.
2. Begin with the patient information section. Fill in the last name, first name, and middle name, alongside the patient's age, birthdate, sex, and primary language.
3. Provide complete contact information for the referring physician, including their full name and address, as well as a telephone number.
4. Indicate the reason for visiting the neurology specialist clearly and thoroughly.
5. In the past medical history section, detail any hospitalizations, operations, head injuries, and include dates wherever applicable.
6. List any previous diagnostic tests such as PET scans, MRIs, and CTs, including the dates and locations where these tests were performed.
7. Complete the social history section by indicating tobacco, caffeine, alcohol, recreational drug use, exposure to toxins, employment status, level of education, marital status, and residential information.
8. Compile the medication list, including current and recent medications. Specify dosages and frequencies for each medication. Also, check whether the patient has used certain common medications and note any drug allergies.
9. Fill out the family history by stating whether relatives are living or deceased, their ages, and their health problems.
10. In the review of systems section, mark any current symptoms experienced by the patient.
11. Specify who is completing the questionnaire and their relationship to the patient.
12. For physician information, list all relevant doctors along with their specialty, contact information, and any necessary fax numbers.
13. Lastly, you may wish to review the behavior checklist, marking any current problems experienced by the patient.
14. Once the questionnaire is completely filled out, ensure to save changes, download, print, or share the form as necessary.

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