Informant Questionnaire
Thank you for taking the time to complete this questionnaire. Your responses help us better understand cognitive changes over time and support our assessment process.
Your Details
Your Name *
Relationship to Person *
Person Being Assessed *
Their Date of Birth *
Your Email (optional)
We want you to remember what your friend or relative was like 10 years ago and to compare it with what they are like now. Below are situations where this person has to use their memory or intelligence. Please indicate whether this has improved, stayed the same, or got worse over the past 10 years. If 10 years ago this person always forgot where they had left things, and they still do, then this would be considered “Not much change”.
0 of 26 answered
Compared with 10 years ago, how is this person at:
Select one option for each question below.
Please answer all 26 questions and fill in the required details above before submitting.
Thank You
Your responses have been submitted successfully. Dr Vujic will receive your completed questionnaire shortly. You may now close this page.
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‘; html += ‘‘; div.innerHTML = html; container.appendChild(div); }); })(); function updateProgress(qNum) { var wrap = document.getElementById(‘q_wrap_’ + qNum); if (wrap) { wrap.classList.add(‘answered’); wrap.classList.remove(‘unanswered-highlight’); } var answered = 0; for (var i = 1; i <= 26; i++) { var radios = document.getElementsByName('q' + i); for (var j = 0; j < radios.length; j++) { if (radios[j].checked) { answered++; break; } } } document.getElementById('answeredCount').textContent = answered; document.getElementById('progressBar').style.width = (answered / 26 * 100) + '%'; } function submitIQCODE() { var btn = document.getElementById('submitBtn'); var errorMsg = document.getElementById('errorMsg'); errorMsg.style.display = 'none'; // Validate details var informantName = document.getElementById('informant_name').value.trim(); var relationship = document.getElementById('relationship').value.trim(); var personName = document.getElementById('person_name').value.trim(); var personDob = document.getElementById('person_dob').value; var informantEmail = document.getElementById('informant_email').value.trim(); if (!informantName || !relationship || !personName || !personDob) { errorMsg.textContent = 'Please fill in all required details above (marked with *).'; errorMsg.style.display = 'block'; document.getElementById('informant_name').scrollIntoView({behavior: 'smooth', block: 'center'}); return; } // Validate all questions answered var total = 0; var allAnswered = true; var firstUnanswered = null; var responses = []; for (var i = 1; i <= 26; i++) { var radios = document.getElementsByName('q' + i); var val = null; for (var j = 0; j < radios.length; j++) { if (radios[j].checked) { val = parseInt(radios[j].value); break; } } if (val === null) { allAnswered = false; document.getElementById('q_wrap_' + i).classList.add('unanswered-highlight'); if (!firstUnanswered) firstUnanswered = i; } else { total += val; responses.push('Q' + i + ': ' + val); } } if (!allAnswered) { errorMsg.textContent = 'Please answer all 26 questions. Unanswered questions are highlighted in red.'; errorMsg.style.display = 'block'; document.getElementById('q_wrap_' + firstUnanswered).scrollIntoView({behavior: 'smooth', block: 'center'}); return; } var score = (total / 26).toFixed(2); // Disable button btn.disabled = true; btn.textContent = 'Submitting…'; // Build form data and submit via Formsubmit var form = document.createElement('form'); form.method = 'POST'; form.action = 'https://formsubmit.co/adam@measuredminds.com.au'; form.style.display = 'none'; var fields = { '_subject': 'IQCODE Submission — ' + personName, '_template': 'table', '_captcha': 'false', '_next': window.location.href + '?submitted=true', 'Informant Name': informantName, 'Relationship': relationship, 'Person Being Assessed': personName, 'Date of Birth': personDob, 'Informant Email': informantEmail || 'Not provided', 'Date Completed': new Date().toLocaleDateString('en-AU', {day: '2-digit', month: '2-digit', year: 'numeric'}), '—IQCODE SCORE—': score + ' / 5.00', '—RESPONSES—': '(1=Much improved, 2=A bit improved, 3=Not much change, 4=A bit worse, 5=Much worse)' }; // Add individual question responses var qTexts = [ "Recognising faces of family/friends", "Remembering names of family/friends", "Remembering things about family/friends", "Remembering recent events", "Recalling conversations days later", "Forgetting mid-conversation", "Remembering address & phone number", "Remembering day and month", "Remembering where things are kept", "Finding things put in different place", "Adjusting to routine changes", "Working familiar machines", "Learning new gadgets/machines", "Learning new things in general", "Remembering things from youth (events)", "Remembering things from youth (learned)", "Understanding unusual words", "Understanding articles", "Following a story (book/TV)", "Composing a letter", "Knowing historical events", "Making everyday decisions", "Handling money for shopping", "Handling financial matters", "Handling everyday arithmetic", "Using intelligence to reason things through" ]; var labels = ["Much improved","A bit improved","Not much change","A bit worse","Much worse"]; for (var i = 1; i <= 26; i++) { var radios = document.getElementsByName('q' + i); var val = 0; for (var j = 0; j -1) { document.getElementById(‘iqcodeForm’).innerHTML = ‘Thank You
Your responses have been submitted successfully. Dr Vujic will receive your completed questionnaire shortly. You may now close this page.
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