English
English
Testing date:
Patient name:
Date of birth:
Please ask an informant who knows the patient well. If you don't have an informant available today, you can skip this part and complete it later. The informant interview can be completed over the phone at any time.
Does the patient have more trouble remembering things that have happened recently than she used to?
Does he or she have more trouble recalling conversations a few days later?
When speaking, does the patient have more difficulty in finding the right word or tend to use the wrong words more often?
Is the patient less able to manage money and financial affairs (e.g. paying bills, budgeting)?
Is the patient less able to manage his or her medication independently?
Does the patient need more assistance with transport (either private or public)? (If the patient has difficulties only due to physical problems, e.g. bad leg, tick ‘no’.)
ASSESSMENT
Cognitive impairment is indicated. Conduct standard investigations. Please refer to the guidelines for your country on the National Guidelines page.
No significant cognitive impairment. Further testing not necessary. Follow-up in 12 months.
RESPONSES
Does the patient have more trouble remembering things that have happened recently than she used to? ...
Does he or she have more trouble recalling conversations a few days later? ...
When speaking, does the patient have more difficulty in finding the right word or tend to use the wrong words more often? ...
Is the patient less able to manage money and financial affairs (e.g. paying bills, budgeting)? ...
Is the patient less able to manage his or her medication independently? ...
Does the patient need more assistance with transport (either private or public)? (If the patient has difficulties only due to physical problems, e.g. bad leg, tick ‘no’.) ...
SAVE & PRINT THIS TEST
Patient name:
Date of birth:
粵語
Deutsch
Español
Français
Italiano
Eλληνικά
한국어
Polski
Română
русский