Clinician: Dr. Eleanor Vance, Clinical Psychologist
Patient: Sarah Jenkins
Date of Birth: 12 March 1965 (59 years old)
Informant: Mr. David Jenkins, husband, daily contact
REFERRAL INFORMATION
Date of assessment: 1 November 2024
Referrer: Dr. Alistair Finch, General Practitioner
Reason for Referral: Progressive memory decline and difficulties with daily planning over the past 18 months, impacting independent living.
Specific referral questions to be addressed: Clarify the nature and extent of cognitive deficits, rule out reversible causes, and guide future management and support needs.
Reports, records, or correspondence received or reviewed: GP referral letter dated 15 October 2024, MRI scan report (brain) dated 1 September 2024.
PATIENT DEMOGRAPHICS
Sarah Jenkins is a 59-year-old right-handed female of Caucasian ethnicity who prefers to communicate in English. She is married and lives with her husband in their semi-detached home.
PRESENTING CONCERNS
Sarah's own understanding of the reason for the assessment is that she's "forgetful" and her "brain isn't as sharp as it used to be." She expresses primary cognitive concerns about her memory, particularly recalling recent events and conversations, and difficulty managing household finances. Emotionally, she feels frustrated and occasionally tearful, and her husband has noticed she's become more irritable.
Onset: Gradual
Duration of the concern: Approximately 18 months.
Course: Progressive, with a noticeable worsening in the last 6 months.
Precipitating or triggering factors: No clear precipitating factors identified; symptoms appear to have emerged insidiously.
Impact on daily functioning: Significant impact on managing household tasks, forgetting appointments, and difficulty following complex instructions.
Memory
Sarah reports frequent word-finding difficulties, often forgetting names of common objects or people. She struggles to remember what she has eaten for breakfast and often repeats questions. Her husband confirms these observations.
Attention and Concentration
She finds it hard to concentrate on television programmes or books for extended periods and is easily distracted by background noise. She reports feeling overwhelmed in busy environments.
Executive Function
Significant difficulties with planning and organising daily activities, such as grocery shopping or preparing meals. Her husband has taken over managing the household budget due to her struggles.
Language
Reports occasional anomia (word-finding difficulties) and difficulty following multi-step instructions. Spontaneous speech can be somewhat tangential.
Visuospatial and Perceptual Skills
No specific visuospatial or perceptual symptoms were reported by Sarah. Her husband noted she has had a few minor bumps with the car when parking, which is unusual for her.
Processing Speed
Reports feeling slower in her thinking and processing information, especially when under pressure.
Praxis
No specific praxis-related symptoms were discussed or reported.
Social Cognition
Her husband notes she has become less empathetic and occasionally makes socially inappropriate comments, which is a change from her premorbid personality.
INFORMANT ACCOUNT
Mr. David Jenkins, Sarah's husband of 30 years, lives with her daily and provides her primary support. He has known Sarah for 35 years. Mr. Jenkins corroborates Sarah's reports of memory loss and executive dysfunction, noting a marked decline in her ability to manage household finances and plan activities. He provides additional details, stating the changes began approximately 18 months ago, initially subtle, but have been steadily progressive, particularly in the last six months. He describes a significant impact on Sarah's independence, as she now relies heavily on him for tasks she previously managed independently, such as driving and complex meal preparation. He also notes changes in her personality, stating she has become more withdrawn, irritable, and occasionally disinhibited. Mr. Jenkins expresses concern about Sarah wandering if left alone for extended periods. He reports discrepancies between Sarah's self-report and his observations, as she often downplays the severity of her difficulties. Mr. Jenkins admits to feeling significant carer burden and stress.
NEUROLOGICAL HISTORY
Neurological diagnoses discussed: Mild Cognitive Impairment, suspected probable Alzheimer's disease (pending further assessment).
Date of onset or diagnosis for each neurological condition: Initial diagnosis of MCI 6 months ago.
Neuroimaging results discussed: MRI scan on 1 September 2024 showed generalised mild cortical atrophy, more pronounced in the medial temporal lobes, consistent with early neurodegenerative changes.
Neurosurgical history: None.
Seizure history including type, frequency, date of last seizure, and current seizure control: No history of seizures.
Head injury history including number of injuries, severity, duration of loss of consciousness, duration of post-traumatic amnesia, and mechanism of injury: One mild concussion at age 25 with no loss of consciousness, fully recovered within a week. No other significant head injuries.
History of central nervous system infection: None.
GENERAL MEDICAL HISTORY
Chronic medical conditions discussed: Hypertension (well-controlled with medication), Type 2 Diabetes Mellitus (diagnosed 5 years ago, managed with diet and metformin).
Cancer history including type, treatment received, and dates: No history of cancer.
Sleep disorders discussed: Reports occasional insomnia, often waking early and struggling to fall back asleep.
Sensory impairments in hearing or vision, and whether corrected: Presbyopia (corrected with reading glasses), mild age-related hearing loss (not yet requiring hearing aids).
Chronic pain including type, location, severity, and duration: Occasional lower back pain (mild, intermittent, no current functional limitation).
Relevant infectious disease history: No relevant history.
Surgical history: Appendectomy at age 15, Tonsillectomy at age 7.
Significant hospital admissions: No significant hospital admissions in the past 10 years.
PSYCHIATRIC HISTORY
Current psychiatric diagnoses: None.
Past psychiatric diagnoses: History of mild depression in early adulthood (age 30), treated with CBT for 6 months with good resolution. No recurrence.
Age of first contact with mental health services: 30 years old.
Previous psychological or psychotherapeutic interventions including type, duration, and outcome: CBT for depression, 6 months, good outcome.
Previous psychiatric admissions including dates and reasons: None.
History of self-harm or suicidal ideation or attempts: None.
History of psychotic symptoms: None.
Current mental health team involvement: None.
MEDICATION
* Ramipril 5mg once daily
* Metformin 500mg twice daily
Medication adherence: Generally good, though occasionally forgets morning dose of Metformin, as reported by her husband.
Recent medication changes: No recent changes.
Past psychotropic medications and reasons for discontinuation: Sertraline for depression (age 30), discontinued after 6 months due to resolution of symptoms.
Known medication side effects experienced: None reported for current medications.
Use of over-the-counter medications or supplements: Daily multivitamin, occasional paracetamol for back pain.
SUBSTANCE USE HISTORY
Alcohol use including current intake in units per week, pattern of use, history of heavy or hazardous use, and longest period of abstinence: Reports consuming 7-10 units of alcohol per week (1-2 glasses of wine most evenings). No history of heavy or hazardous use. Longest period of abstinence was during pregnancy (9 months).
Tobacco or nicotine use, current and past, including quantity: Smoked 5-10 cigarettes per day from age 18 to 35, quit cold turkey. No current tobacco or nicotine use.
Cannabis use, current and past, including frequency and duration: Reports occasional cannabis use in her early 20s (less than once a month for approx. 2 years), ceased spontaneously. No current use.
Other recreational substance use including type, frequency, route, and duration: None.
History of substance misuse or dependence: None.
Previous treatment or detoxification: None.
Current recovery status: N/A.
DEVELOPMENTAL HISTORY
Pregnancy and birth history including complications, prematurity, or low birth weight: Unremarkable pregnancy and full-term birth. No complications reported.
Early developmental milestones including motor and language development, and any delays: Achieved all motor and language milestones within typical ranges. No reported delays.
Childhood health including febrile convulsions, meningitis, or chronic illness: One episode of chickenpox in childhood. No other significant childhood illnesses or febrile convulsions.
Childhood behavioural or emotional difficulties: No significant behavioural or emotional difficulties reported.
History of neurodevelopmental conditions such as ADHD, autism spectrum disorder, learning disability, dyslexia, or dyspraxia: No history of diagnosed neurodevelopmental conditions.
History of childhood abuse or trauma: No reported history of childhood abuse or trauma.
Social services involvement in childhood: None.
EDUCATIONAL HISTORY
Schools attended and type of schooling, including any special educational provisions: Attended local comprehensive school. No special educational provisions.
Academic attainment and qualifications, including highest level achieved: Left school at 18 with 3 A-levels (English Literature, History, Art) and 8 O-levels (including Maths and English).
Learning difficulties identified, and whether formally assessed: No learning difficulties identified or formally assessed during schooling.
Statement of Special Educational Needs or Education, Health and Care Plan: No such statements or plans.
Academic strengths and weaknesses: Strong in humanities and arts; found mathematics more challenging but achieved a passing grade.
Further or higher education: Completed a Bachelor of Arts degree in English Literature at a Russell Group university.
Current functional literacy and numeracy: Able to read newspapers and novels, but struggles with complex financial calculations.
OCCUPATIONAL HISTORY
Current employment status: Retired since age 55.
Current or most recent occupation and role: Secondary School Teacher (English Literature), retired 4 years ago.
Key employment history and duration of roles: After university, worked as a librarian for 5 years, then became a secondary school English teacher for 28 years. Consistently employed.
Reason for leaving most recent role: Voluntarily retired.
Highest level of occupational attainment: Head of English Department.
Work-related cognitive or interpersonal difficulties: No significant difficulties reported prior to retirement. Recent onset of cognitive issues would likely impact her ability to teach effectively.
Receipt of disability-related benefits: Not currently receiving any disability-related benefits.
Medico-legal involvement: None.
SOCIAL AND PERSONAL HISTORY
Current living arrangements: Lives with her husband in their owner-occupied house.
Key relationships including partner, children, and close family: Married to David for 30 years. Has two adult children who visit weekly. Close relationship with her sister who lives nearby.
Quality of social network and level of social support: Good quality social network, receives strong support from her husband and children. Regular contact with a few close friends.
Social activities and engagement: Prior to onset of symptoms, regularly attended a book club and a walking group. Now attends less frequently due to fatigue and difficulty following conversations.
Hobbies and interests, current and premorbid: Premorbidly enjoyed reading, gardening, and painting. Now finds reading challenging and has lost interest in painting. Still enjoys short walks in the garden.
Changes in social functioning or personality: Has become more withdrawn, less sociable, and occasionally irritable, as observed by her husband.
Carer responsibilities held by the patient: None.
Care package in place: No formal care package, primarily supported by her husband.
Driving status and whether DVLA has been notified if relevant: Still holds a driving licence, but her husband reports her driving has become more hesitant and he has advised her to avoid long journeys. DVLA has not yet been notified.
Financial management including whether independent or supported: Previously managed family finances independently. Now supported by her husband due to difficulties.
Safeguarding concerns: Husband reports concerns about her occasionally leaving the gas hob on and wandering in the garden at night.
FAMILY HISTORY
Family history of neurological conditions: Maternal grandmother diagnosed with Alzheimer's disease in her late 70s.
Family history of psychiatric conditions: Paternal uncle had a history of depression.
Family history of learning disability or neurodevelopmental conditions: None reported.
Other relevant family medical history: Father had hypertension and died of a myocardial infarction at 72.
PREMORBID FUNCTIONING
Estimated premorbid intellectual level based on educational, occupational, and demographic information discussed: High premorbid intellectual level, supported by her degree and successful career as a Head of English Department.
Languages spoken and proficiency levels: Native English speaker, proficient in French (learned at school and university).
Reading habits and engagement with cognitively demanding activities: Premorbidly an avid reader of complex literature, regularly engaged in crossword puzzles and intellectual discussions.
Cultural considerations relevant to assessment and interpretation: No specific cultural considerations identified that would significantly impact assessment or interpretation.
CURRENT FUNCTIONAL STATUS
Basic Activities of Daily Living
Personal hygiene and grooming: Independent, but occasionally needs prompting from husband.
Dressing: Independent.
Eating and nutrition: Independent, but rarely prepares complex meals independently.
Continence: Fully continent.
Mobility: Independent, no difficulties with walking or balance.
Instrumental Activities of Daily Living
Meal preparation: Requires significant assistance from husband; can only manage simple tasks like making toast.
Household management: Requires substantial assistance; struggles with cleaning, laundry, and organising.
Shopping: Can participate in shopping with her husband, but cannot manage independently (e.g., forgets items, gets lost).
Managing finances: No longer manages finances independently; husband has taken over.
Managing medications: Needs reminders from husband to take her medication consistently.
Using transport: Can use public transport with her husband, but no longer uses it independently. Still drives short distances, but with increasing difficulty.
Using technology such as phone or computer: Can answer the phone but struggles to make calls or use a computer.
Managing correspondence: Cannot manage correspondence independently; husband handles bills and important letters.
Changes from premorbid level of functioning: Marked decline in all instrumental activities of daily living and some basic ADLs compared to premorbidly independent functioning.
CURRENT MOOD AND MENTAL STATE
Current mood as described by the patient: Reports feeling "low" and "frustrated" with her memory. Denies suicidal ideation.
Anxiety symptoms: Reports feeling anxious in new situations or when she feels her memory is being tested. Experiences generalised worry about her future.
Sleep pattern: Reports difficulty falling asleep and early morning waking. Sleeps approximately 5-6 hours per night, described as unrefreshing.
Appetite and weight changes: Appetite is unchanged. Reports a stable weight over the last year.
Fatigue and energy levels: Experiences significant fatigue, often needing to rest during the day.
Motivation and any apathy: Marked reduction in motivation for previously enjoyed activities, consistent with some apathy.
Irritability or agitation: Husband reports increased irritability, particularly when frustrated with cognitive tasks.
Behavioural changes such as disinhibition, compulsive behaviours, or rigidity: Husband reports occasional disinhibition, such as making inappropriate comments in public.
MENTAL STATE OBSERVATIONS
Appearance: Well-groomed and appropriately dressed. Maintains good eye contact.
Behaviour and rapport during interview: Cooperative and engaged, though sometimes appeared to struggle to retrieve information. Maintained good rapport throughout.
Speech including rate, volume, fluency, and coherence: Speech was of normal rate and volume, but with frequent word-finding pauses and occasional circumlocution. Generally coherent.
Affect and mood as observed by the clinician: Affect was restricted, with periods of mild sadness and frustration. Mood appeared congruent with stated concerns.
Thought content: No evidence of delusional ideation or preoccupations. Expressed concerns about memory and future independence.
Perceptual disturbances: Denied any hallucinations or perceptual disturbances.
Orientation to time, place, and person: Fully oriented to person and place. Partially oriented to time (knew the month but not the exact date or day of the week).
Insight and awareness of difficulties: Partial insight; acknowledges memory problems but tends to minimise their impact on daily life. Husband reports more significant concerns.
BEHAVIOURAL OBSERVATIONS DURING INTERVIEW
Engagement and motivation: Generally engaged and motivated to participate, but became visibly fatigued towards the end of the 90-minute interview.
Response to difficulty or frustration: Showed mild frustration when struggling to recall specific details, often sighing or looking to her husband for help.
Fatigue effects observed during the interview: Became slower in her responses and more prone to word-finding difficulties as the interview progressed.
Anxiety or emotional responses during discussion of sensitive topics: Became tearful when discussing the impact of her memory problems on her independence and her husband's increased caring responsibilities.
Distractibility: Easily distracted by minor noises outside the room.
Need for repetition or rephrasing of questions: Required several questions to be repeated or rephrased, particularly those involving complex abstract concepts.
Qualitative communication features such as tangentiality, circumstantiality, word-finding pauses, or pragmatic difficulties: Noted occasional tangential responses and frequent word-finding pauses.
Factors noted that may affect the validity or interpretation of subsequent cognitive assessment: Fatigue and anxiety during testing may impact performance. Partial insight may affect self-report accuracy.
**Neuropsychological Assessment Report Template**
Clinician:
[Clinician's name and job title] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Patient:
[Patient name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Date of Birth:
[Date of birth and age] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Informant:
[Name, relationship, and frequency of contact of any informant present at the interview] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**REFERRAL INFORMATION**
Date of assessment:
[Date of assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Referrer:
[Referral source and referring service] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Reason for Referral:
[Reason for referral] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Specific referral questions to be addressed:
[Specific referral questions to be addressed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Reports, records, or correspondence received or reviewed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
**PATIENT DEMOGRAPHICS**
[Patient name, gender, ethnicity, preferred language, handedness, marital status, and current living situation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Write in a single paragraph of full sentences, starting with the patient's name.)
**PRESENTING CONCERNS**
[Patient's own understanding of the reason for the assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[Patient's primary cognitive, emotional, and behavioural concerns described in their own words] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[Onset of concerns including whether sudden, gradual, or stepwise] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Duration of the concern] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Course of concerns including whether stable, progressive, fluctuating, or improving] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Precipitating or triggering factors] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Impact on daily functioning] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Memory
[Memory-related symptoms discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Attention and Concentration
[Attention-related symptoms discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Executive Function
[Executive function symptoms discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Language
[Language symptoms discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Visuospatial and Perceptual Skills
[Visuospatial symptoms discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Processing Speed
[Processing speed symptoms discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Praxis
[Praxis-related symptoms discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Social Cognition
[Social cognition symptoms discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
**INFORMANT ACCOUNT**
[Informant's name, relationship to the patient, duration of relationship, living situation, and frequency and nature of contact] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Write in a single paragraph of full sentences.)
[Informant's account of the patient's cognitive, emotional, and behavioural changes, including confirmation of patient's reports and any further details or examples] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[Onset and timeline of changes from the informant's perspective] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Course of changes from the informant's perspective including whether stable, progressive, fluctuating, or improving] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Impact on the patient's independence as described by the informant] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Impact on the patient's relationships or social functioning as described by the informant] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Changes in the patient's personality noted by the informant] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Safety concerns raised by the informant] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Discrepancies between the patient's self-report and the informant's account] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Informant's own wellbeing or carer burden] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**NEUROLOGICAL HISTORY**
[Neurological diagnoses discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Do not invent or infer a diagnosis.)
[Date of onset or diagnosis for each neurological condition] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Neuroimaging results discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Neurosurgical history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Seizure history including type, frequency, date of last seizure, and current seizure control] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Head injury history including number of injuries, severity, duration of loss of consciousness, duration of post-traumatic amnesia, and mechanism of injury] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[History of central nervous system infection] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**GENERAL MEDICAL HISTORY**
[Chronic medical conditions discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
[Cancer history including type, treatment received, and dates] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Sleep disorders discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Sensory impairments in hearing or vision, and whether corrected] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Chronic pain including type, location, severity, and duration] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Relevant infectious disease history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Surgical history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Significant hospital admissions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**PSYCHIATRIC HISTORY**
[Current psychiatric diagnoses] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank. Do not invent or infer a diagnosis.)
[Past psychiatric diagnoses] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.)
[Age of first contact with mental health services] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Previous psychological or psychotherapeutic interventions including type, duration, and outcome] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Previous psychiatric admissions including dates and reasons] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[History of self-harm or suicidal ideation or attempts] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[History of psychotic symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Current mental health team involvement] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**MEDICATION**
[Current medications including name, dose, and frequency for each] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as list. Do not include the indication.)
[Medication adherence] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Recent medication changes] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Past psychotropic medications and reasons for discontinuation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Known medication side effects experienced] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Use of over-the-counter medications or supplements] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**SUBSTANCE USE HISTORY**
[Alcohol use including current intake in units per week, pattern of use, history of heavy or hazardous use, and longest period of abstinence] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
[Tobacco or nicotine use, current and past, including quantity] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Cannabis use, current and past, including frequency and duration] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Other recreational substance use including type, frequency, route, and duration] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[History of substance misuse or dependence] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Previous treatment or detoxification] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Current recovery status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**DEVELOPMENTAL HISTORY**
[Pregnancy and birth history including complications, prematurity, or low birth weight] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
[Early developmental milestones including motor and language development, and any delays] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Childhood health including febrile convulsions, meningitis, or chronic illness] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Childhood behavioural or emotional difficulties] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[History of neurodevelopmental conditions such as ADHD, autism spectrum disorder, learning disability, dyslexia, or dyspraxia] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.)
[History of childhood abuse or trauma] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Social services involvement in childhood] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**EDUCATIONAL HISTORY**
[Schools attended and type of schooling, including any special educational provisions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
[Academic attainment and qualifications, including highest level achieved] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Learning difficulties identified, and whether formally assessed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Statement of Special Educational Needs or Education, Health and Care Plan] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Academic strengths and weaknesses] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Further or higher education] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Current functional literacy and numeracy] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**OCCUPATIONAL HISTORY**
[Current employment status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
[Current or most recent occupation and role] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Key employment history and duration of roles] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Reason for leaving most recent role] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Highest level of occupational attainment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Work-related cognitive or interpersonal difficulties] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Receipt of disability-related benefits] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Medico-legal involvement] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**SOCIAL AND PERSONAL HISTORY**
[Current living arrangements] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
[Key relationships including partner, children, and close family] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Quality of social network and level of social support] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Social activities and engagement] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Hobbies and interests, current and premorbid] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Changes in social functioning or personality] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Carer responsibilities held by the patient] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Care package in place] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Driving status and whether DVLA has been notified if relevant] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Financial management including whether independent or supported] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Safeguarding concerns] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**FAMILY HISTORY**
[Family history of neurological conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
[Family history of psychiatric conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Family history of learning disability or neurodevelopmental conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Other relevant family medical history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**PREMORBID FUNCTIONING**
[Estimated premorbid intellectual level based on educational, occupational, and demographic information discussed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
[Languages spoken and proficiency levels] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Reading habits and engagement with cognitively demanding activities] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Cultural considerations relevant to assessment and interpretation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**CURRENT FUNCTIONAL STATUS**
Basic Activities of Daily Living
[Personal hygiene and grooming] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
[Dressing] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Eating and nutrition] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Continence] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Mobility] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Instrumental Activities of Daily Living
[Meal preparation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Household management] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Shopping] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Managing finances] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Managing medications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Using transport] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Using technology such as phone or computer] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Managing correspondence] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Changes from premorbid level of functioning] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**CURRENT MOOD AND MENTAL STATE**
[Current mood as described by the patient] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
[Anxiety symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Sleep pattern] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Appetite and weight changes] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Fatigue and energy levels] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Motivation and any apathy] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Irritability or agitation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[Behavioural changes such as disinhibition, compulsive behaviours, or rigidity] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**MENTAL STATE OBSERVATIONS**
[Appearance] (Only include if the clinician explicitly commented on this during the session, else leave blank.)
[Behaviour and rapport during interview] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Speech including rate, volume, fluency, and coherence] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Affect and mood as observed by the clinician] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Thought content] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Perceptual disturbances] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Orientation to time, place, and person] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Insight and awareness of difficulties] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
**BEHAVIOURAL OBSERVATIONS DURING INTERVIEW**
[Engagement and motivation] (Only include if the clinician explicitly commented on this during the session, else leave blank.)
[Response to difficulty or frustration] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Fatigue effects observed during the interview] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Anxiety or emotional responses during discussion of sensitive topics] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Distractibility] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Need for repetition or rephrasing of questions] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Qualitative communication features such as tangentiality, circumstantiality, word-finding pauses, or pragmatic difficulties] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
[Factors noted that may affect the validity or interpretation of subsequent cognitive assessment] (Only include if the clinician explicitly commented on this during the session, else omit section entirely.)
