{"slug": "appendix-2-dementia-register-form-d2", "title": "\u2018For persons not applying for anti dementia medication D2\u2019 (Annex 2).", "pdfUrl": "https://dhir.gov.mt/wp-content/uploads/2024/02/appendix-2-dementia-register-form-D2.pdf", "sourcePage": "https://dhir.gov.mt/en/registries/dementia/", "group": "Registry", "topic": "Dementia", "tables": [{"caption": "Appendix 2", "header": ["Dementia Register Form for persons not applying for anti-dementia medication D2", "", "", "", "Registration no:(for office use only)"], "rows": [["Part 1: To be completed always:", "", "", "", ""], ["Name:", "", "", "ID No:", ""], ["Surname:", "", "", "DOB:", ""], ["Address:", "", "", "Sex:", "M       F"], ["Locality:", "", "", "Post code:", ""]]}, {"caption": "Table 2: Part 2: To be completed when first diagnosed with dementia", "header": ["Educational Levelcompleted:", "post-non-tertiary", "Social Status:", "", "S      M     W     SepDiv", ""], "rows": [["Resident at:", "", "Specify:                   Specify:", "", "", ""], ["", "", "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 Dementia", "Lewy-", "", "", ""], ["Clinic:", "", "", "", "", ""], ["Radiology:", "CT", "Date:", "", "", ""], ["", "MRI", "Date:", "", "", ""], ["", "SPECT", "Date:", "", "", ""], ["Behavioural andPsychological Sypt:", "", "", "", "", ""], ["Behavioural andPsychological Sypt:", "", "", "", "", ""], ["Anti-dementiaMedication:", "", "Side-effects fromAnti-dementia medication:", "", "", ""], ["Anti-dementiaMedication:", "", "Side-effects fromAnti-dementia medication:", "", "", ""], ["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:", ""], ["Anti-dementiaMedication:", "", "Side-effects from", ""], ["Anti-dementiaMedication:", "", "Anti-dementiamedication:", ""], ["PsychiatricTreatment:", "", "Side-effects of", ""], ["PsychiatricTreatment:", "", "Psychiatric treatment:", ""], ["PsychiatricTreatment:", "", "", ""], ["Current housingLocation:", "Specify:                          Specify:", "", ""]]}, {"caption": "Table 4: Part 4: To be completed always", "header": ["Consultant:", "", "Signature:", ""], "rows": [["Reg No:", "", "", ""]]}]}