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Patient: Assessed by: Date Completed: PATIENT COGNITIVE ASSESSMENT FORM 1. Ask the patient to listen carefully to and remember following 3 words and then to repeat the words back to you: Ocean Desk.

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Three-Word Recall Examples would be “banana, sunrise, chair,” or “daughter, heaven, mountain.” Then the test-taker is asked to draw a clock (see below). After completing the drawing, the test-taker is asked to repeat the three words that were spoken at the beginning of the test.

Examples would be “banana, sunrise, chair,” or “daughter, heaven, mountain.” Then the test-taker is asked to draw a clock (see below). After completing the drawing, the test-taker is asked to repeat the three words that were spoken at the beginning of the test.

The Mini-Cog test. A third test, known as the Mini-Cog, takes 2 to 4 minutes to administer and involves asking patients to recall three words after drawing a picture of a clock. If a patient shows no difficulties recalling the words, it is inferred that he or she does not have dementia.

Mini-Cog1 and Mini-Cog2 A three-point technique is used for scoring: one point for drawing a circle, one point for drawing the correct numbers on the clock, and one point for drawing the hands in the correct position. A score of 3 is considered normal.

The five-minute cognitive test (FCT) was designed to capture deficits in five domains of cognitive abilities, including episodic memory, language fluency, time orientation, visuospatial function, and executive function.

The Self-Administered Gerocognitive Exam (SAGE) is a brief self-administered cognitive screening instrument used to identify mild cognitive impairment (MCI) from any cause and early dementia.

The Mini-Cog© is a fast and simple screening test to help detect dementia in its early stages. In just 3 minutes, Mini-Cog© can help doctors and other professional care providers identify possible cognitive impairment in older patients.

Short-term memory/delayed recall: Five words are read. The test-taker is asked to repeat them. After completing other tasks, the person is asked to repeat each of the five words again. If they can't recall them, they're given a cue of the category that the word belongs to.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232