COGNITIVE PACKET

Please fill out the following Packet.

It is recommended to be filled out by your care partner (spouse, family member, friend).

This helps us better understand your current medical condition and how we can provide the best care to you.

Patient Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.

Person Completing Packet: Name:

Relationship to Patient, (SELECT 1 ANSWER)

SpouseFamily MemberGuardianOther

If selected "Family Member" or "Other", please specify

Do you have ANY of the following: Durable Power of Attorney for healthcare, Living will, and/or 'DNR' Do-Not-Resuscitate orders?

NoYes

Which of the Following Do you Have in Place?

Durable Power of Attorney for Healthcare (Medical)Living Will"DNR" Do-Not-Resuscitate Orders

Source of Information (Please select ONE):

Care partnerPatient

1. The following descriptions characterize changes you have noticed in your cognitive and functional abilities. You are asked to compare your abilities now to how they used to be – the key feature is change.

2. Check one answer for each category that you think best fits you at the present time.

NOTE – not all descriptions need to be present to choose an answer.

1. MEMORY AND RECALL

0: No obvious memory loss or slight inconsistent forgetfulness that does not interfere with your everyday function0.5: Consistent mild forgetfulness or partial recollection of events that may interfere with performing your everyday activities; repeats questions/statements, misplaces items, forgets appointments1: Mild to moderate memory loss; more noticeable for recent events; interferes with performing your everyday activities2: Moderate to severe memory loss; only highly learned information remembered; new information rapidly forgotten3: Severe memory loss, almost impossible to recall new information; long-term memory may be affected

2. ORIENTATION

0: Fully oriented to person, place, and time nearly all the time0.5: Slight difficulty keeping track of time; may forget day or date more frequently than in the past1: Mild to moderate difficulty keeping track of time and sequence of events, forgets month or year, oriented to familiar places but gets confused outside of familiar areas; gets lost or wanders2: Moderate to severe difficulty, usually disoriented to time and place (familiar and unfamiliar); frequency dwells in the past3: Only oriented to your name, although may recognize family members

3. DECISION MAKING AND PROBLEM SOLVING ABILITIES

0: Solves everyday problems; handles personal business and financial affairs well; decision-making abilities consistent with your past performance0.5: Slight impairment or takes longer to solve problems; trouble with abstract concepts; decisions still sound1: Moderate difficulty with handling problems and making decisions, defers many decisions to others; social judgment and behavior may be slightly impaired; loss of insight2: Severely impaired in handling problems, making only simple personal decisions; social judgement and behavior often impaired; lacks insight3: Unable to make decisions or solve problems; others make nearly all decisions for you

4. ACTIVITIES OUTSIDE THE HOME

0: Independent in function at usual level of performance in profession, shopping, community activities, religious services, volunteering or social groups0.5: Slight impairment in these activities compared to previous performance; slight change in driving skills; still able to handle emergency situations1: Unable to function independently but still may attend and be engaged; appears “normal” to others; notable changes in driving skills; concern about ability to handle emergency situations2: No pretense of independent function outside the home; appears well enough to be taken to activities outside the family home but generally needs to be accompanied by someone3: No independent function or activities; appear too ill to be taken to activities outside the home

5. FUNCTION AT HOME AND HOBBY ACTIVITIES

0: Chores at home, hobbies and personal interests are well maintained compared to your past performance0.5: Slight impairment or less interest in these activities; trouble operating appliances (particularly new purchases)1: Mild but definite impairment in home and hobby function; more difficult chores or tasks abandoned; more complicated hobbies and interests given up2: Only simple chores preserved, very restricted interest in hobbies which are poorly maintained3: No meaningful function in household chores or with prior hobbies

6. TOILETING AND PERSONAL HYGEINE

0: Fully capable of self-care (dressing, grooming, washing, bathing, toileting)0.5: Slight changes in abilities and attention to these activities1: Needs prompting to complete these activities but may still complete independently2: Requires some assistance in dressing, hygiene, keeping of personal items; occasionally incontinent3: Requires significant help with personal care and hygiene; frequent incontinence

7. BEHAVIOR AND PERSONALITY CHANGES

0: Socially appropriate behavior in public and private; no changes in personality0.5: Questionable or very mild changes in behavior, personality, emotional control, appropriateness of choices1: Mild changes in behavior or personality2: Moderate behavior or personability changes, affects interactions with others; may be avoided by friends or distance family3: Severe behavior or personality changes; making interactions with others unpleasant or avoided all together

8. LANGUAGE AND COMMUNICATION ABILITIES

0: No language difficulty or occasional word searching; reads and writes as well as in past0.5: Consistent mild word finding difficulties, using descriptive terms or takes longer to get point across, mild problems with comprehension, conversation, writing and/or reading1: Moderate word finding difficulty in speech, cannotname objects, marked reduction in work production; reduced comprehension,conversation, writing and/or reading2: Moderate to severe impairments in speech production or comprehension; has difficulty communicating thoughts to others; limitedability to read or write3: Severe deficits in language and communication; little to no understandable speech

9. MOOD

0: No changes in your mood, interest or motivation level0.5: Occasional sadness, depression, anxiety, nervousness or loss of interest/motivation1: Daily mild issues with sadness, depression, anxiety, nervousness or loss of interest/motivation2: Moderate issues with sadness, depression, anxiety, nervousness or loss of interest/motivation3: Severe issues with sadness, depression, anxiety, nervousness or loss of interest/motivation

10. ATTENTION AND CONCENTRATION

0: Normal attention, concentration and interaction with your environment and surroundings0.5: Mild problems with attention, concentration, and interaction with environment and surroundings, may appear drowsy during the day1: Moderate problems with attention and concentration, may have staring spells or spend time with eyes closed, increased daytime sleepiness2: Significant portion of the day is spent sleeping, not paying attention to environment, when having a conversation may say things that are illogical or not consistent with topic3: Limited to no ability to pay attention to external environment or surroundings

Total Score QDRS

	YES	NO
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel full of energy?
4. Do you feel that your life is empty?
5. Are you in good spirits most of the time?
6. Do you often get bored?
7. Do you feel happy most of the time?
8. Do you prefer to stay at home, rather than going out and doing new things?
9. Do you think it is wonderful to be alive now?
10. Are you afraid that something bad is going to happen to you?
11. Do you often feel helpless?
12. Do you think that most people are better off than you are?
13. Do you feel you have more problems with memory than most?
14. Do you feel pretty worthless the way you are now?
15. Do you feel that your situation is hopeless?

	Not at all	Several days	More than half the days	Nearly every day
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

	YES	NO
1. Does patient show moderate changes in their level of functioning during the day?
2. Between getting up in the morning and going to bed at night, dose the patient spend more than 1 hour sleeping?
3. Is the patient drowsy and lethargic for more than 1 hour during the day, despite getting their usual amount of sleep the night before?
4. Is it moderately difficult to arouse the patient so they maintain attention throughout the day?

COGNITIVE PACKET

Advance Care Planning

QDRS

Bristol Activities of Daily Living Scale

GDS (Short Form)

GAD-7

SYMPTOMS CHECKLIST

COGNITIVE PACKET SCORING SUMMARY