{"slug": "appendix-1-dementia-register-form-d1", "title": "\u2018For persons on anti-dementia medication D1\u2019 (Annex 1)", "pdfUrl": "https://dhir.gov.mt/wp-content/uploads/2024/02/appendix-1-dementia-register-form-D1.pdf", "sourcePage": "https://dhir.gov.mt/en/registries/dementia/", "group": "Registry", "topic": "Dementia", "tables": [{"caption": "Appendix 1", "header": ["Dementia Register Form for persons on anti-dementia medication D1", "", "", "", "Registration no: (for office use only)", "", "", ""], "rows": [["Part 1: To be completed always", "", "", "", "", "", "", ""], ["Name:", "", "ID No:", "", "", "", "", ""], ["Surname:", "", "DOB:", "", "", "", "", ""], ["Address:", "", "Sex:", "", "F M", "", "", ""], ["Locality:", "", "Post code:", "", "", "", "", ""]]}, {"caption": "Table 2: Part 2: To be completed when applying for dementia drugs for the first time", "header": ["Educational Levelcompleted:", "post-non-", "", "", "", "Social Status:", "", "S      M     W     SepDiv", ""], "rows": [["Resident at:", "Own", "", "", "", "Specify:                   Specify:", "", "", ""], ["", "Own", "", "", "", "Specify:                   Specify:", "", "", ""], ["Living status:", "", "", "", "", "", "", "", ""], ["Main Carer (Name):", "", "", "", "", "Main Carer (Relation):", "", "", ""], ["Main Carer (Tel No):", "", "", "", "", "Own telephone no:", "", "", ""], ["Referred by (GP):", "", "", "", "", "Date of referral :", "", "", ""], ["Reason for referral:", "", "", "", "", "Date of 1stattendance tospecialist clinic:", "", "", ""], ["Diagnosis Status:", "", "", "", "", "Date of Diagnosis:", "", "", ""], ["MMSE score:", "", "", "", "", "Barthel Score:", "", "", ""], ["Dementia Sub-Type:", "Alzheimer\u2019s DiseaseFronto-temporal DementiaOther", "", "", "", "", "", "Mixed DementiaLewy-", ""], ["Clinic:", "RHKG", "", "", "", "Other", "", "", ""], ["", "", "", "", "", "Other", "", "", ""], ["Radiology:", "CT", "", "", "", "Date:", "", "", ""], ["", "MRI", "", "", "", "Date:", "", "", ""], ["", "SPECT", "", "", "", "Date:", "", "", ""], ["Behavioural andPsychological Sypt:", "", "", "", "", "", "", "", ""], ["Behavioural andPsychological Sypt:", "", "", "", "", "", "", "", ""], ["Dementia Treatment:", "", "", "", "", "Side-effects ofDementia treatment:", "", "", ""], ["Dementia Treatment:", "", "", "", "", "Side-effects ofDementia treatment:", "", "", ""], ["PsychiatricTreatment:", "", "", "", "", "Side-effects of psychiatricmedication:", "", "", ""], ["PsychiatricTreatment:", "", "", "", "", "Side-effects of psychiatricmedication:", "", "", ""], ["PsychiatricTreatment:", "", "", "", "", "Side-effects of psychiatricmedication:", "", "", ""]]}, {"caption": "Table 3: Part 3: To be completed during all subsequent visits", "header": ["Date of visit:", "", "", ""], "rows": [["MMSE score:", "", "Barthel score:", ""], ["DementiaTreatment:", "", "Side-effects ofdementia treatment:", ""], ["DementiaTreatment:", "", "Side-effects ofdementia treatment:", ""], ["PsychiatricTreatment:", "", "Side-effects ofPsychiatric treatment:", ""], ["PsychiatricTreatment:", "", "Side-effects ofPsychiatric treatment:", ""], ["PsychiatricTreatment:", "", "", ""], ["Current housingLocation:", "Specify:                          Specify:", "", ""]]}, {"caption": "Table 4: Part 4: To be completed always", "header": ["Consultant:", "", "Signature:", ""], "rows": [["Reg No:", "", "", ""]]}]}