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Name
Label/Question
1.

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

2.

Subject ID

Subject ID: __ __ __ __

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

3.

Report date

Report Date:

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

4.

Event

Acute Baseline Alert/Adverse Event (Mark all that apply)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

5.

Event, specify

If Acute Baseline Alert/Adverse Event: CG Severe medical problem, Specify: ____________________

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

6.

Date event month

Date of Acute Baseline Alert/Adverse Event: Month

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

7.

Date event day

Date of Acute Baseline Alert/Adverse Event: Day

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

8.

Date event year

Date of Acute Baseline Alert/Adverse Event: Year

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

9.

Treatment related

Acute Baseline Alert/Adverse Event: Treatment Related?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

10.

Status of event

Acute Baseline Alert/Adverse Event: Event status resolved/controlled?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

11.

Resolution date month

Date of Resolution - Acute Baseline Alert/Adverse Event (if applicable): Month

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

12.

Resolution date day

Date of Resolution - Acute Baseline Alert/Adverse Event (if applicable): Day

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

13.

Resolution date year

Date of Resolution - Acute Baseline Alert/Adverse Event (if applicable): Year

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

14.

REACH certification number

2. REACH II Certification Number: __ __ __ __

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AE: Caregiver/Care Recipient Acute Baseline Alerts/Adverse Events Forms Guidebook.

15.

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

16.

Report date

Report Date:

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

17.

Subject ID

Subject ID: __ __ __ __

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

18.

Date event month

Date of Acute Baseline Alerts/Adverse Events: Month

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

19.

Date event day

Date of Acute Baseline Alerts/Adverse Events: Day

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

20.

Date event year

Date of Acute Baseline Alerts/Adverse Events: Year

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

21.

Event

Event Code

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

22.

Resolution date month

Date of Resolution - Acute Baseline Alert/Adverse Event: Month

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

23.

Resolution date day

Date of Resolution - Acute Baseline Alert/Adverse Event: Day

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

24.

Resolution date year

Date of Resolution - Acute Baseline Alert/Adverse Event: Year

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

25.

REACH certification number

1.1. Reach II Certification Number: __ __ __ __

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - AF: Acute Baseline Alerts/Adverse Events Follow-Up Report Guidebook.

26.

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

27.

Subject ID

Subject ID: __ __ __ __

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

28.

Which time point

1. Which interview is taking place?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

29.

Which time point specify

If 6 month follow-up interview is taking place, 1.1. Specify type:

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

30.

Baseline start date

2. Date interview started:

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

31.

Baseline end date

3. Date interview completed:

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

32.

CG consent to participate

Baseline battery only: 6. Has the caregiver (CG) given consent to participate in the study?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

33.

CR consent to participate

Baseline battery only: 7. Has the care recipient (CR) given consent to participate in the study or has proxy consent been obtained? ... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

34.

Date score

MMSE 1. Please tell me today's date. Can you tell me what (month, date, year, day, season) it is? Score _____ (Maximum Score = 5)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

35.

Building score

MMSE 2. Can you tell me what building we are in right now? (Building, floor, city, county, state) Score _____ (Maximum Score = 5)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

36.

Number of trials

MMSE I'm going to name three objects, and I'd like you to repeat them after me, ok? (Name three objects, allotting one second to say each.) APPLE ... TABLE ... PENNY Give 1 point for each correct answer on the first trial only. Repeat the ... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

37.

Object score

MMSE I'm going to name three objects, and I'd like you to repeat them after me, ok? (Name three objects, allotting one second to say each.) APPLE ... TABLE ... PENNY Score _____ (Maximum Score = 3) ... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

38.

Math score

MMSE 4. I'm going to ask you to do some subtraction. Think of the number 7. I want you to subtract 7 from 100. Now subtract 7 from that and keep going until I stop you. Score ____ (Maximum Score = 5) ... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

39.

World score

MMSE 5. I want you to spell a word forward and then backward. The word is 'WORLD.' Spell it forward. ____ ____ ____ ____ ____ (If incorrect, then correct the participant and allow him/her to respell it until he/she spells it correctly.) Sp... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

40.

Recall score

MMSE 6 . Do you remember a few minutes ago I had you repeat some words after me? Can you tell me what they were? (Give 1 point for each correct answer) Score _____ (Maximum Score = 3) ... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

41.

Name these score

MMSE 7. Please name these for me. (Show the participant a wooden pencil and a watch, preferably worn on the wrist. Score 1 point for each correct answer.) Score _____ (Maximum Score = 2) ... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

42.

Repeat sentence score

MMSE 8. I'm going to read a sentence and I want you to repeat it after me. Say exactly what I say, ok? NO IFS, ANDS, OR BUTS. Score _____ (Maximum Score = 1; Score 1 point only if every word is repeated correctly.) ... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

43.

Paper score

MMSE 9. Now I'm going to ask you to do something for me. I'm only going to say it once, so listen carefully. Take this paper in your right hand; Fold the paper in half with both hands; and put the paper in your lap. Score _____ (Maximum Sc... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

44.

Close eyes score

MMSE 10. Read this card, and do what the card tells you to do. (Show the card with close your eyes on it. One prompt allowed after initial instructions. Score 1 point.) Score _____ (Maximum Score = 1) ... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

45.

Write sentence score

MMSE 11. Now please write a sentence for me on this blank piece of paper. (Do not dictate a sentence or provide a subject; it must be written spontaneously. Prompt as often as you like. The sentence must contain a subject and verb and be s... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

46.

Copy design score

MMSE 12. Please copy this design exactly as it is for me. (Hold the card with the design on it in front of the participant; do not let the participant trace the design. All 10 angles must be present and 2 must intersect to score 1 point. T... (view details)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

47.

Total score

13. Total MMSE Score: _____

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

48.

MMSE = 0

14. Is the MMSE Total Score = 0?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

49.

22 hours in bed chair

15. Does (CR) spend at least 22 hours a day in a bed or chair?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

50.

Care recipient bedbound

If (CR) does spend at least 22 hours a day in a bed or chair, 15.1. Has this occurred for at least 4 of the past 7 days?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health (REACH II), 2001-2004 - BA: Baseline Battery Guidebook.

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