Part A 1. Did the patient consult with a doctor from their own initiative (as opposed to the process being initiated by family/friends/colleagues)? Yes No 2. Is there a past history of mood, anxiety, psychotic or personality disorders? Yes No 3. Is the patient emotionally distressed (dysphoria, anxiety) by the current situation? Yes No 4. Is the patient expressing guilt, self-blame, and/or suicidal thoughts? Yes No 5. Is the main complaint of the family that the patient has anger problems? Yes No 6. Is the patient aware of and/or concerned about cognitive or behavioral changes? Yes No 7. Are the cognitive or behavioral symptoms fluctuating? Yes No 8. Is the patient showing interest in learning about the possibility of having FTD? Yes No 9. Does the patient understand what FTD is when provided with some explanations (at a level expected for a healthy person with the same education)? Yes No 10. Is the patient reporting more severe disability than expected based on clinical and cognitive examination? Yes No 11. Is there a legal or financial compensation issue motivating the consultation process? Yes No 12. Are the patient and/or relatives upset or doubtful if told they might not have FTD (as opposed to expressing relief, joy, etc.)? check No if this did not happen Yes No Part B 13. Is there a 1st degree family history of FTD or ALS? Yes No 14. Are there language related complaints? Yes No 15. Are there stereotypical or simple repetitive behaviors? Yes No 16. Are there changes in food preferences? Yes No 17. Are there abnormalities on elemental neurological examinations (including eye movement, parkinsonism, ALS, paratonia, primitive reflexes)? Yes No Merci !
